Credentialing Criteria and Standards

Keystone First VIP Choice (HMO SNP) applies credentialing and re-credentialing criteria for all professional providers that, at a minimum, meet the requirements of 42 CFR 422.502 (i) (4) (iv).

Keystone First VIP Choice (HMO SNP)'s criteria include:

  1. Current medical licensure.
  2. No revocation or suspension of the provider's state license by the Board of Medicine and Surgery.
  3. Disclosure related to ownership and management (42 CFR 455.104), business transactions (42 CFR 455.105) and conviction of crimes (42 CFR 455.106).
  4. Proof of the provider's medical school graduation, completion of residency and other postgraduate training. Evidence of board certification is accepted in lieu of proof of medical school graduation, residency and other postgraduate training.
  5. Evidence of specialty board certification, if applicable.
  6. Evidence of the provider's professional liability claims history.
  7. Satisfactory review of any sanctions imposed on the provider by Medicare or Medicaid.
  8. The provider's Medicare identification number, Medicaid ID number, Medicaid provider registration number or documentation of submission of the Medicaid provider registration form whenever applicable.

In addition, Keystone First VIP Choice (HMO SNP)'s credentialing and re-credentialing processes include verification of the following additional requirements for physicians:

  1. For primary care physicians and specialists - privileges in good standing at the hospital designated by the PCP as the primary admitting facility; or, if the PCP does not have admitting privileges, privileges in good standing at the hospital for another provider with whom the PCP has entered into an arrangement for hospital coverage.
  2. Valid Drug Enforcement Administration (DEA) certificate, where applicable.

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Providers