Preferred Providers Credentialing Intro

Letter to Applicant .......................................................................................................1 An Introduction to First Choice Health ................................................................................3

Standard of Quality ................................................................................................................................... 3 Who is FCH?............................................................................................................................................. 3 Governed by Community Business Leaders.............................................................................................. 3

First Choice Health Specialty Listing .................................................................................4 Minimum Requirements for Credentialing...........................................................................7 FCH Allied Health Care Provider Requirements.....................................................................8 Instructions for Completion of the Application .................................................................... 13 First Choice Health Criteria for Provider Denial (Initial Applicant) or Provider Termination .............. 15 First Choice Health’s PPO Network Appeals Process............................................................. 17

Level One Appeal .................................................................................................................................... 17 Level Two Appeal.................................................................................................................................... 18

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Dear Applicant: First Choice Health’s PPO Network is a provider sponsored Preferred Provider Organization (PPO) and is a network of hospitals, physicians and ancillary health care providers, incorporated in 1984. First Choice Health (FCH) contracts with providers for negotiated fee discounts with FCH Payors and credentials those providers who have been nominated or request to join our PPO Network. An application for your completion, as well as information provided for your records is available for you to download. Please complete the entire application and return it along with the necessary attachments. Any information omitted will delay the process of your application. Please allow a minimum of 90 days to process your application for credentialing. Upon completion of the credentialing process, you will be notified of your contract effective date. Your effective date will be the first day of the month following favorable peer review of your application. Please note that your First Choice Health patients will not be eligible for maximum benefits for services rendered prior to your membership effective date.

The following documents are available for our information/completion:

• Introduction to First Choice Health • FCH Specialty/Subspecialty Listing • Minimum Requirements for Credentialing • FCH Allied Health Care Provider Requirements • Instructions for completing the application • Practitioner Application – The Washington Practitioner Application (WPA) is accepted for providers practicing in

Washington, Alaska, Idaho and Oregon. If you have already completed a Statewide Credentialing Application for Idaho or Oregon, FCH will accept that application as long as it is current and completed in its entirety.

• Practitioner Attestation Questions • Practitioner Authorization and Release of Information Form • FCH Criteria for Denial of a Credentialing or Recredentialing Application • FCH Appeals Process • First Choice Health Network Preferred Provider/Group Agreement • Request for Taxpayer Identification Number & Certification (W-9)

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If it is determined that your application does not document the minimum required standards for network participation, it will not be processed. Such non-processing will not constitute a denial; it will, however, mean that you are not eligible for network participation. Thus, your application will not be presented to the Credentialing Committee for a decision. Such non-processing is not considered a reportable action. You will be notified in writing if we determine we are unable to process your application. Additionally, you have the right to review information obtained by FCH to evaluate your credentialing application. The review must be scheduled, in advance, through the Credentialing Department. In the event that the credentialing information obtained from other sources varies substantially from what you have provided, you will be notified in writing and given an opportunity to correct incomplete, inaccurate and/or conflicting information in support of your credentialing application. You will be informed, in writing, of any discrepancies found during the credentialing process (within 30 days of the discovery). You will be given 30 days after receipt of the notification to respond to the Credentialing Department. In the event no response is received, a second/final request for information will be forwarded. The FCH Credentialing Program prohibits discrimination on the basis of race, color, religion, gender, national origin, sexual orientation, marital status, age, types of procedures or types of patients the practitioner specializes in, or any other protected classification. You have the right to be informed of your application status. If you have any questions please contact the Credentialing Department at 800-231-6935 ext. 2106. PPO Network Credentialing Department Enclosures

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An Introduction to First Choice Health Employers are making determined efforts to control their healthcare costs yet still ensure that employees and their families have access to quality care through a wide variety of providers. First Choice Health, based in Seattle, Washington, offers a solution that more and more employers find attractive. By providing access to care at a reduced cost through select credentialed networks of healthcare providers, First Choice Health helps its clients and their employees to significantly lower health care costs without sacrificing quality. First Choice Health is the Preferred Provider Organization (PPO Network) for over 7,000 employer groups in Washington, Idaho, Oregon and Alaska.

Standard of Quality Patient health care is important to us. Therefore, selecting and retaining quality providers and facilities is one of our primary concerns. First Choice Health credentials all providers with whom we sign contracts, and we recredential them every three years to ensure ongoing compliance with our standards of performance. Our Credentialing Committee meets monthly to provide peer-review oversight of our credentialing process. First Choice Health’s provider selection and credentialing process reflects our commitment to promoting quality health care.

Who is FCH? First Choice Health organizes and manages networks of providers and facilities who contractually agree to provide care at reduced cost. Some of our clients access our network only, while others additionally benefit from our Employee Assistance Program, Medical Management, and Third Party Administration products. Our PPO Network currently consists of more than 100 hospitals and over 30,000 healthcare providers. First Choice Health is not an insurance company. Insurance functions, such as creating benefit plans, collecting premiums, processing and paying claims, and answering questions regarding benefits and eligibility, are handled by the insurers, third party administrators (TPAs), union trusts, self-insured employer groups and other health care ‘payors’ with whom we do business. Most First Choice Health payors support direct claim submission and provider payment, which helps keep the paperwork for almost 1 million enrollees to a minimum.

Governed by Community Business Leaders Incorporated in 1984 as a for-profit corporation, First Choice Health is governed by an eleven member board of directors with representatives from both the health care and business communities. Ken Hamm is President and CEO, and Ze’ev Young, MD, is Chief Medical Officer.

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First Choice Health Specialty Listing Approved by Credentialing Committee on 2/14/2007 Specialty/Description Specialty/Description Acupuncture Genetics, Clinical Addiction Medicine Genetics, Medical Adolescent Medicine Geriatric Medicine

Aerospace Medicine Gynecologic Oncology Allergy & Immunology Gynecology Anesthesiology Hematology/Oncology

Audiology Hospitalist Cardiac Electrophysiology Immunopathology Cardiac Surgery Infectious Disease

Cardiovascular Disease Internal Medicine CertifiedNutritionist/Registered Dietitian Interventional Cardiology Certified Registered Nurse Anesthetist (CRNA) Licensed Professional Counselors

Child Neurology Marriage & Family Counselor Chiropractor Massage Therapy Clinical & Laboratory Immunology Maternal & Fetal Medicine

Clinical Neurophysiology Maxillofacial Surgery Colon & Rectal Surgery Medical Microbiology Critical Care Medicine Medical Toxicology

Cytogenetics, Clinical Metabolism Cytopathology MOHS Micrographic Surgery Dermatological Immunology Naturopathic Physician

Dermatology Neonatal – Perinatal Medicine Dermatopathology Neonatal Medicine Emergency Medicine Nephrology

Endocrinology Neurodevelopmental Disabilities FAA Examiner Neurological Surgery Facial & Plastic Surgery Neurology

Family Practice Neuro-Ophthalmology Family Practice w/Ob Neuropathy Gastroenterology Neuropsychology

General Practice Neuroradiology General Surgery Neurology

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Specialty/Description Specialty/Description Nuclear Medicine Pediatric, Otolaryngology Nurse Midwife Certified/Licensed Pediatric, Pathology

Nurse Practitioner Pediatric, Pulmonology Nurse Practitioner/Adult Pediatric, Radiology Nurse Practitioner/Enterostomal Therapy Pediatric, Rehabilitation Medicine

Nurse Practitioner/Family Practice Pediatric, Rheumatology Nurse Practitioner/Geriatric Pediatric, Sports Medicine Nurse Practitioner/Mental Health Pediatric, Surgery

Nurse Practitioner/Neonatal Pediatric, Urology Nurse Practitioner/Neonatal-Perinatology Pediatrics Nurse Practitioner/Pediatric Perinatal Medicine

Nurse Practitioner/Perinatology Physical Medicine and Rehabilitation Nurse Practitioner/Women's Health Physical Therapy Obstetrics Physician Assistant

Occupational Medicine Plastic & Reconstructive Surgery Occupational Therapy Plastic Surgery Obstetrics & Gynecology Plastic Surgery within the Head and Neck

Ophthalmology Podiatry Optometry Preventive Medicine Orthopaedic Surgery Prosthetist/Orthotist

Osteopathic Manipulation Psychiatry, Child/Adolescent Otolaryngology Psychiatry, Forensic Otolaryngology, Pediatric Psychiatry, Geriatric

Otology Psychiatry Otology/Neurotology Psychiatry, Addiction Otorhinolaryngolgy Psychoanalysis

Pain Management Psychology Pathology Public Health Pediatric, Allergy/Immunology Public Health & General Preventive Medicine

Pediatric, Cardiology Pulmonary Disease Pediatric, Critical Care Medicine Radiation Oncology Pediatric, Dermatology Radiation Therapy

Pediatric, Developmental/Behavioral Radiology Pediatric, Emergency Medicine Radiology, Nuclear Pediatric, Endocrinology Radiology, Diagnostic

Pediatric, Gastroenterology Radiology, Interventional Pediatric, Hematology-Oncology Radiology, Theraputic Pediatric, Infectious Diseases Radiology, Ultrasound

Pediatric, Nephrology Radiology, Vascular & Interventional Pediatric, Neurosurgery Registered Nurse/First Assistant Pediatric, Opthalmology Registered Nurse/Surgical Assistant

Pediatric, Orthopaedics Reproductive Endocrinology

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Specialty/Description Specialty/Description

Rheumatology Surgery, Oral & Maxilliofacial

Sleep Disorder Medicine Surgical Critical Care Social Work Thoracic & Cardiac Surgery Speech Language Pathology Thoracic Surgery

Spinal Cord Injury Tropical Medicine Sports Medicine Underseas & Hyperbaric Medicine Substance Abuse/Chemical Dependency Urgent Care

Surgery, Hand Urology Surgery, Head & Neck Vascular Surgery

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Minimum Requirements for Credentialing Eligibility for participation is based on the following minimum requirements:

1. A current, valid unrestricted license/certification or authorization to practice.

2. No restrictions on licensure, registration/certification or authorization to practice, including but not limited to, probationary status, chaperon requirements or prescribing limitations.

3. A current, valid, unrestricted DEA Registration or CDS Certificate (for prescribing applicants).

4. Clinical privileges at a FCH contracted hospital or an In Patient Covering (if applicable). a) Primary Care Attending Coverage: Each primary care practitioner/group is required to assure a 365

days, 24 hour inpatient coverage schedule for patients requiring hospitalization from their practice/group or an identified Hospitalists Program. All physicians providing call coverage for inpatients need to have privileges in good standing at the appropriate institution.

b) Specialty Consultation and Attending Coverage: Each sub specialist/group will assure that subspecialty consultation is available for all patients at identified institutions by specialists who have privileges in good standing. This subspecialty service will be available 365 day a year and 24 hours a day.

5. Graduation from a medical school that is approved by the State Licensing Board or other school that is appropriate to the provider specialty.

6. Completion of a residency program which meets the standards of the Accreditation Committee on Graduate Medical Education or the Council on Post Doctoral Training of the American Osteopathic Association (AOA).

7. Current board certification in practice specialty. Candidates must become board certified within five years of completion of residency training (if applicable).

8. Work history for preceding five years. Please account for any gaps of six months or more.

9. Current malpractice coverage with limits of one million ($1,000,000) per incident, three million ($3,000,000) per aggregate.

c) Self Insured Providers must provide evidence of “committed assets” in an amount equivalent to a one million ($1,000,000) per incident and three million ($3,000,000) per aggregate general comprehensive liability policy. By “committed assets” FCH means that assets that are dedicated solely to the purpose of payment of professional liability claims incurred by any of the Clinic and/or Provider(s), which cannot be accessed by general creditors or any of the Provider(s), and which can reasonably be converted to cash for the payment of professional liability claims resulting in whole or in part from the negligent act or omission of any of the Provider(s) occurring during any period in which the Clinic and/or the Provider(s) is contracted with FCH.

d) Doctor of Chiropractic Medicine - Malpractice coverage limits of two hundred thousand ($200,000) per incident, six hundred thousand ($600,000) per aggregate.

10. Proof of professional liability coverage for the past five years, including address and policy numbers.

11. Also reference: Additional requirements for Allied HealthCare Practitioners

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FCH Allied Health Care Provider Requirements Last Update 5/2007 Practitioner Type FCH Education/Training

Requirements for Network Participation

Additional FCH Requirements for Network Participation.

Acupuncturist Graduation from a NCCAOM accredited or state approved school. *Verification of licensure confirms state approval of Program and/or accreditation Program (WA, AK, ID, OR)

None

Advanced Registered Nurse Practitioner

Graduation from an approved nurse practitioner program and has an active ARNP license and an active RN license to practice. *Verification of licensure confirms state approval of Program and/or accreditation Program (WA, AK, ID, OR)

National Certification Exam Bodies are: • American Nurses Credentialing Center

(ANCC)

• National Certification Corporation (NCC)

• American Academy of Nurse Practitioners (AANP)

• Hospital Admitting Privileges or in-patient covering plan (If practicing as a PCP)

• Certified Registered Nurse Anesthetists (CRNA’s) must be certified by the Council on Certification of Nurse Anesthetists

Audiologist Masters degree in Audiology from a recognized institution of higher learning. *Verification of licensure confirms state approval of Program and/or accreditation Program (WA, AK, ID, OR)

• Certification by the American Speech Language-Hearing Association (ASHA) and/or

• Certification by the American Board of Audiology (approved on 7/12/2006)

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Practitioner Type FCH Education/Training Requirements for Network Participation

Additional FCH Requirements for Network Participation.

Chiropractor Graduation from an accredited chiropractic college approved by the Chiropractic Quality Assurance. Commission. *Verification of licensure confirms state approval of Program and/or accreditation Program (WA, AK, ID, OR)

Chiropractors are required to carry malpractice coverage with limits of two hundred thousand (200,000) per incident, six hundred thousand (600,000) per aggregate.

Dentist Graduation from a dental school approved by the Dental Quality Assurance Commission. *Verification of licensure confirms state approval of Program and/or accreditation Program (WA, AK, ID, OR)

None.

Dietician Bachelors degree or higher in major course study in human nutrition, foods and nutrition, dietetics, or food management. *Verification of licensure confirms state approval of Program and/or accreditation Program (WA, AK, ID, OR)

None

Marriage and Family Therapist

Masters or Doctoral degree in any Behavioral Science. *Verification of licensure confirms state approval of Program and/or accreditation Program (WA, AK, ID, OR)

None

Massage Practitioner Completion of a State Board of Massage Education Program. *Verification of licensure confirms state approval of Program and/or accreditation Program (WA, AK, ID, OR)

None

Mental Health Counselor

Masters or Doctoral degree in Mental Health Counseling or related field from a regionally accredited college or university.

None

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Practitioner Type FCH Education/Training Requirements for Network Participation

Additional FCH Requirements for Network Participation.

Midwife/Certified Nurse Midwife

Graduation from an approved nurse practitioner program. Has an active RN license to practice and graduation from an approved midwifery program. *Verification of licensure confirms state approval of Program and/or accreditation Program (WA, AK, ID, OR)

• Certification by the American College of Nurse Midwives.

• A written, formal patient coverage arrangement with a FCH contracted obstetrical physician.

Midwife/Licensed Nurse Midwife

Graduation from an approved midwifery program. *Verification of licensure confirms state approval of Program and/or accreditation Program (WA, AK, ID, OR)

• Have a written, formal patient coverage arrangement with a contracted obstetrical physician.

• A copy of the current plan (filed with the state) for consultation with a medical doctor (MD or DO) in an obstetrical practice, emergency transfer and transport client. The physician must be contract with FCH. Reference: RCW 18.50.108.

Neuropsychologist Doctoral degree in psychology from accredited university training program. Internship or its equivalent in the specialty of Neuropsychology.

None

Naturopath Graduation from a state approved naturopathic school. *Verification of licensure confirms state approval of Program and/or accreditation Program (WA, AK, ID, OR)

Hospital Admitting Privileges or In Patient Covering Plan (if identified as a PCP)

Nutritionist Masters or doctorate in Nutrition. *Verification of licensure confirms state approval of Program and/or accreditation Program (WA, AK, ID, OR)

None

Occupational Therapist Graduation from a nationally accredited, Board approved school. *Verification of licensure confirms state approval of Program and/or accreditation Program (WA, AK, ID, OR)

None

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Practitioner Type FCH Education/Training Requirements for Network Participation

Additional FCH Requirements for Network Participation.

Optometrist Graduation from an accredited School of Optometry accredited by the Council on Optometric Education of American Optometric Association and approved by the sate licensing board. *Verification of licensure confirms state approval of Program and/or accreditation Program (WA, AK, ID, OR)

None

Physical Therapist Graduation from a nationally accredited, Board approved school. *Verification of licensure confirms state approval of Program and/or accreditation Program (WA, AK, ID, OR)

None

Physician Assistant Graduation from an accredited or approved physician assistant program. *Verification of licensure confirms state approval of Program and/or accreditation Program (WA, AK, ID, OR) or AAPA Physician Assistant Profile satisfies this requirement.

• National Commission on Certification of Physician Assistants

• A copy of the Utilization Plan filed with the State. The sponsoring physician must be a FCH contracted provider.

• Hospital Admitting Privileges or In Patient Covering Plan (if identified as a PCP)

• Additional Requirements Surgical Assistants:

• National Surgical Assistant Association or National Commission on Certification of Physician Assistants with additional training in surgery

Podiatrist Graduation from an accredited or approved podiatric school. *Verification of licensure confirms state approval of Program and/or accreditation Program (WA, AK, ID, OR)

Certification by the American Board of Podiatric Surgery or Certification by the American Board of Podiatric Orthopedics and Primary Medicine

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Practitioner Type FCH Education/Training Requirements for Network Participation

Additional FCH Requirements for Network Participation.

Psychologist Doctoral Degree from a regionally accredited or APA approved school. *Verification of licensure confirms state approval of Program and/or accreditation Program (WA, AK, ID, OR)

None

Registered Counselor Masters degree from a fully accredited program. *Verification of licensure confirms state approval of Program and/or accreditation Program (WA, AK, ID, OR)

• Must be on network prior to 1/1/2005 (considered “grandfathered”).

• Also reference: Mental Health Counselor.

Registered Nurse First Surgical Assistant (RNFA)

Bachelor’s degree from a fully accredited program. *Verification of licensure confirms state approval of Program and/or accreditation Program (WA, AK, ID, OR)

• Certification by the Certification Board of Preoperative Nursing (CNOR).

• Documentation of a written formal agreement to practice in collaboration with and under the on-site supervision and direction of a FCH contracted physician.

Social Worker Masters degree in social work from an accredited graduate school of social work. *Verification of licensure confirms state approval of Program and/or accreditation Program (WA, AK, ID, OR)

None

Speech and Language Pathologist

Masters in Speech Pathology from a recognized institution of higher learning. *Verification of licensure confirms state approval of Program and/or accreditation Program (WA, AK, ID, OR)

Certification by the American Speech Language-Hearing Association (ASHA)

Surgical Assistant Graduate of a fully accredited program.

National Surgical Assistant Association or National Commission on Certification of Physician Assistants with additional training in surgery

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Instructions for Completion of the Application Last Update 5/2007

Please allow a minimum of 90 days to process applications for credentialing. The provider will be notified upon completion of the credentialing process and will be given an effective date for First Choice Health PPO Network participation.

• All sections on the Practitioner Application must be completed. Necessary explanations must be provided. If a section is not applicable to you, check the “Does not apply box” or write “N/A”.

• Practitioner Attestation Questions – Answer all questions. A detailed explanation of any “yes” answers must be provided.

• Authorization and Release of Information Agreement – Sign and date.

• Your specialty and/or subspecialty must be recognized by FCH (see attached).

• First Choice Health Preferred Provider/Group Agreement – Complete appropriate information, sign and date. • Request for Taxpayer Identification Number and Certification (W-9) – Complete the appropriate information, sign

and date. • Please submit the following items with the application:

• A copy of your current state medical license or certificate of registration.

• A copy of your current DEA Registration or CDS Certificate (if applicable).

• A copy of your current certificate of malpractice insurance.

• A copy of your board certification certificate (if applicable)

• A current Curriculum Vitae, which includes five years of work history and all out of state medical license numbers

• Allied Health Care Practitioners must also reference: Additional Requirements for Allied Health Care Practitioners (attached).

If you have any questions, please contact the Credentialing Department at (800) 231-6935 ext. 2106.

Please return all documents in the enclosed envelope to the address identified below:

First Choice Health PPO Network, Inc. One Union Square

ATTN: Credentialing Department (P.O. Box 2449) 600 University Street Suite 1400 Seattle, WA 98101

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• Upon completion of the initial credentialing process or the recredentialing process, you will be notified within 60 days of Credentialing Committee action.

• You have the right to review information obtained by FCH to evaluate your credentialing application. The review must be scheduled in advance through the Credentialing Department.

• If information provided on the practitioner application is inconsistent with information obtained via primary source verification during the credentialing or recredentialing process, you will be notified, in writing, by the Credentialing Department that FCH has obtained inconsistent information.

• If credentialing information obtained from other sources varies substantially from that you provided, you will be notified, in writing, and given an opportunity to correct incomplete, inaccurate and/or conflicting information in support of your credentialing application.

• You have the right to correct erroneous information submitted by another party (i.e., actions on a license, malpractice claims history, suspension or termination of hospital privileges or board certification status).

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First Choice Health Criteria for Provider Denial (Initial Applicant) or Provider Termination (Recredentialing Applicant or Concurrent Review) The First Choice Health’s PPO Network Credentialing Committee shall approve, deny or terminate participation. Denial or termination based upon quality of care is a reportable issue. The criteria for denying or terminating participation may include, but are not limited to:

1. Submission of inaccurate or misleading information on the application, or failure to disclose relevant information.

2. Inability of FCH to complete the credentialing/recredentialing process due to the applicant’s failure to provide relevant information or the necessary release.

3. Failure to notify FCH of any changes in clinical privileges, any changes in hospital staff privileges, any changes in practice scope; any sanctions or restrictions or any medical or mental health problems that could effect the care of patients.

4. Any current or previous loss of, or revocation, or restrictions to, or limitations or sanctions to professional license, certification/registration or authorization to practice, including but not limited to, probationary status, chaperone requirements or related requirements (i.e., monitoring, open doors, etc), prescribing limitations, required supervision, or restricted hospital privileges.

5. History of practicing without valid license, registration/certification or authorization.

6. Current or previous loss of, or revocation, or restrictions to, DEA certificate.

7. Current or previous loss of or restrictions to hospital, clinic, facility, surgical center, network or other healthcare privileges or scope of practice.

8. Criminal record affecting professional practice.

9. Current or history of a felony conviction.

10. Currently or previously censured or excluded or sanctioned by Medicare/Medicaid and/or by Labor and Industry (L&I).

11. Current or history of chemical dependency or substance abuse.

12. Notification from a confidential program for chemically impaired practitioners (i.e., Washington Physicians Health Program) documenting that they can no longer provide advocacy for the practitioner because of instability in his/her recovery and/or for non-compliance with the Program/Contract.

13. Current physical or mental health condition that may significantly impair the practitioner’s ability to practice within the full scope of licensure and qualifications or may impose a risk of harm to patients.

14. Loss of, or insufficient, or inadequate malpractice insurance coverage.

15. History of malpractice claims judged excessive by the Credentialing Committee. Professional liability claims history is defined as cases that are settled and have resulted in an adverse judgment against the provider.

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16. History of providing patient care outside of the scope of license, registration/certification or authorization.

17. Renders or has rendered any services outside the scope of license, registration/certificate, or other authorization.

18. History of practice trends that raise concerns regarding provider’s ethics, quality of care and/or practice standards.

19. Practice inconsistent with professional standards of care.

20. History of significant patient complaints documented by licensing authority, healthcare facility, health plan, or network administrator.

21. Lack of local hospital admitting privileges or inpatient coverage plan (if applicable).

22. Loss of local hospital admitting privileges or inadequate inpatient coverage plan (if applicable).

23. Failure to become board certified in practice specialty within five years of completion of residency (if applicable). Reference Attachment C.

24. Failure to maintain Board certification in practice specialty for specialties that require periodic recertification (if applicable). Reference Attachment C.

25. Quality issues as reported by National Practitioner Data Bank (NPDB)/Healthcare Integrity Data Bank (HIPDB), licensing boards or prior work/training sites.

26. Refusal, revocation, suspension or restrictions of hospital staff privileges at any hospital.

27. Failure to comply with procedures implemented in connection with the administration of utilization review or failure to cooperate with the quality management activities.

28. Voluntary relinquishment, withdrawal or failure to proceed with an application in order to avoid an adverse action or to preclude an investigation or while under investigation relating to professional competence or conduct.

29. Voluntary relinquishment or withdrawal of clinical privileges in order to avoid an adverse action, or to preclude an investigation, or while under investigation relating to professional competence or conduct.

30. Unethical conduct in violation of laws or standards governing the practice of health care.

31. History of unethical conduct in violation of laws or standards governing the practice of health care.

32. Acts of fraud, deceit, dishonesty or moral turpitude.

33. History of acts of fraud, deceit, dishonesty or moral turpitude.

34. Practice inconsistent with the professional standard of care.

35. Evidence of compromised quality of care.

36. Submission of erroneous, improper, or incomplete claims for payment.

37. Inadequate medical record practices or inappropriate billing practices (i.e., upcoding, failure of adequate chart documentation to support submitted claims, etc).

38. History of or current non-compliance with FCH Provider Contract.

39. Lack of Network and/or membership needs.

When a practitioner’s application to become a contracted practitioner participating in First Choice Health’s lines of business is denied, or when a practitioner’s First Choice Health’s PPO Network contract for participation is terminated, the practitioner shall not be eligible to reapply for participation for a period of at least two (2) years, or until any specified terms of such denial or termination have been satisfied, whichever occurs first.

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First Choice Health’s PPO Network Appeals Process Last Update 5/2007 In the event that First Choice Health places a practitioner on suspension, imposes a corrective action plan, or terminates the practitioner for failure to meet participation criteria, the practitioner has the right to appeal the decision and the right to legal representation. Appeal hearings are set forth herein to assure that the effected practitioner is afforded all rights to which he/she is entitled.

Level One Appeal

1. The practitioner will be notified of termination, suspension, imposition of corrective action plan, or denial within 10 days of the action and/or approval of minutes. The notification will be forwarded via registered certified return receipt mail and will inform the practitioner of his/her right to appeal the decision.

2. Upon receipt of notification of termination, suspension, imposition of corrective action plan, or denial, the practitioner may submit a request for appeal.

3. The appeal must be in writing and must contain details of the practitioner’s issues with the decision or the decision making process.

4. The appeal must be received within 30 days of the date of receipt of the written notice of termination, suspension, imposition of corrective action plan, or denial.

5. Within 10 business days of receipt of the practitioners appeal, the practitioner will be notified in writing (via certified mail)of receipt of appeal and of the anticipated Credentialing Committee review date.

6. The appeal will be reviewed by the Credentialing Committee within 60 business days of receipt of appeal, unless FCH and appealing Provider both agree to a different timeline.

7. The Credentialing Committee will review the appeal and move to uphold or not uphold the original decision by a majority vote.

8. The practitioner will be notified of the outcome within 10 business days of approval of the associated Credentialing Committee minutes. The notification will be forwarded via registered certified return receipt mail.

9. If the decision of the Credentialing Committee is to uphold the original decision, the practitioner will be informed, in writing, of his/her right to request a Level II Appeal.

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Level Two Appeal

1. Practitioner may request in writing a hearing with the Level II Appeals Committee. The request must be received by FCH within 30 days of receipt by the practitioner of the Level One Appeal decision.

2. Within 10 business days of receipt of the practitioners appeal, the practitioner will be notified in writing (via certified mail) of receipt of appeal and of the anticipated Appeals Committee review date.

3. Practitioner will receive a summary of his/her rights and a description of the Level II Appeals process within 10 business days of receipt of request for a Level II Appeal.

4. The appeal will be reviewed by the Appeals Committee within 60 business days of receipt of appeal, unless FCH and appealing Provider both agree to a different timeline.

5. Practitioner will have the right to legal representation. Any costs related to such representation are the practitioner’s responsibility.

6. Practitioner will have a right to receive a full set of all written materials and documentation considered by the Credentialing Committee in making its decision with regard to practitioner.

7. Practitioner will have the right to present information and other documentation determined to be relevant by the hearing officer.

8. Practitioner will have the right to submit a written statement at the close of the hearing.

9. The voting members of the Level II Appeals Committee are appointed by the President & CEO or his/her designee. Voting members will be selected from the FCH Board of Directors, the FCH Quality Improvement Council the FCH Medical Advisory Committee, and/or community health care practitioners. Prior participation in the credentialing process of the appellant disqualifies a candidate from participating in the Level II Appeals Committee.

10. The Level II Appeals Committee will consist of not less than two actively practicing health care practitioners, with at least one of them being in the same practice category (i.e., MD/DO, Naturopath, Chiropractor, etc).

11. Decisions of the Appeals Committee are reached by majority vote. A quorum consists of three voting members, to include at least two (2) health care practitioners.

12. The FCH President and CEO or his/her designee will serve as the hearing officer.

13. At the discretion of the Credentialing Committee, a representative may be appointed to act as a liaison to the Level II Appeals Committee to provide pertinent history summarizing the Credentialing Committee’s decision, if desired by the Level II Appeals Committee.

14. Formal minutes will be taken at the meeting.

15. The Appeals Committee will have access to all written materials and documentation that were reviewed by the Credentialing Committee.

16. Decisions regarding the appeal will be determined by majority vote of the voting members constituting the Level II Appeals Committee.

17. The written notification of the decision will be sent to the practitioner within ten (10) business days of the meeting.

18. The written notification will be sent via registered mail, and the notice will be deemed received and final upon signature and date of the receipt.

19. The decision of the Level II Appeals Committee will be final and binding for all involved parties.

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PLEASE READ THE ENCLOSED CONTRACT CAREFULLY!

Participation with First Choice Health Network requires your signature on the attached Preferred Provider Contract.

FCH must be notified (in writing) of any TIN and/or address changes.

Please submit a Request for Taxpayer Identification Number & Certification (W-9)

Failure to communicate changes to FCH may void your contract

and may cause your patients unnecessary out-of-pocket expenses.