New Claims System Update

11.5 Ongoing Sanction Monitoring

Provider Manual
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11 Credentialing

11.5 Ongoing Sanction Monitoring

To support certain credentialing standards between the recredentialing cycles, IntegraNet has established an ongoing monitoring program. Credentialing performs ongoing monitoring to help ensure continued compliance with credentialing standards and to assess for occurrences that may reflect issues of substandard professional conduct and competence. To achieve this, the credentialing department will review periodic listings/reports within 30 calendar days of the time they are made available from the various sources including, but not limited to, the following:

  • Office of the Inspector General (OIG)
  • Federal Medicare/Medicaid Reports
  • Office of Personnel Management
  • State licensing boards/agencies
  • Health Plan's Customer Services Departments
  • Clinical Quality Management Department (including data regarding complaints of both a clinical and nonclinical       nature, reports of adverse clinical events and outcomes, and satisfaction data, as available)
  • Other internal IntegraNet Departments
  • Any other verified information received from appropriate sources

    • When a practitioner or HDO within the scope of credentialing has been identified by these sources, criteria will be used to assess the appropriate response.