PCHP Initial Credentialing & Recredentialing Process
To be reimbursed for services rendered to Medicaid Managed Care members, providers must be enrolled in Texas Medicaid, complete the initial credentialing process, and have a duly executed contract with PCHP.
PCHP’s credentialing process is consistent with guidelines set forth by the National Committee for Quality Assurance (NCQA), TX Department of Insurance (TDI), TX Health & Human Services Commission (HHSC) and Health Plan requirements. To participate in the Medicaid STAR and CHIP networks, PCHP requires full credentialing of the following office-based health care professionals, but is not limited to:
- Doctor of Chiropractic (DC)
- Doctor of Dental Surgery (DDS)
- Doctor of Dental Medicine (DMD)
- Doctor of Osteopathy (DO)
- Doctor of Podiatry (DPM)
- Medical Doctor (MD)
- Audiologist (AD)
- Nurse Midwife (CNM)
- Nurse Practitioner (NP, APN, ARNP, CNS)
- Optometrist (OD)
- Occupational Therapy (OT)
- Physical Therapy (PT)
- Physician Assistant (PA)
- Speech & Language Pathology (SLP)
Behavioral Health professionals and physicians must contact Carelon at 888-204-5581 or on their website for questions regarding the credentialing or recredentialing process for Medicaid STAR & CHIP networks.
Practitioners must submit all requested information necessary to complete the initial credentialing or recredentialing process. Each practitioner must cooperate with PCHP as necessary to conduct initial credentialing and recredentialing in accordance with PCHP’s policies and procedures.
PCHP utilizes Verisys, a Credentialing Verification Organization (CVO), for all initial credentialing and recredentialing requests. Verisys will collect all initial credentialing or recredentialing applications, forms, licenses, and other relevant documents needed to validate a practitioner’s credentials. The process of validation is called primary source verification (PSV). Verisys will notify PCHP upon completion of the PSV process. A final determination will be made by PCHP whether to approve or deny the practitioner’s participation. A written notification of the final decision will be sent by PCHP to the practitioner.
During the initial credentialing or recredentialing process, PCHP affords practitioners the following rights: 1) Review information submitted in support of the initial credentialing/recredentialing application; 2) Correct any erroneous information; 3) Receive status of initial credentialing/recredentialing application.
PCHP ensures that information gathered during the primary source verification stage is duly reviewed and validated. Practitioners are notified of any discrepancies noted between the credentialing information provided by the practitioner and those obtained from other sources. Practitioners must respond to information requests in writing and address all identified discrepancies. PCHP staff will make up to three attempts to notify practitioners of discrepancies after which the practitioner will be either denied or terminated.
Upon successful completion of the initial credentialing process, the practitioner will be effective in the claims system no later than 90 calendar days following the receipt of a completed initial credentialing application.
In accordance with Texas Insurance Code Chapter 1452, Subchapters C, D, and E, PCHP allows certain practitioner types to request expedited credentialing process. Practitioners eligible for expedited credentialing are physicians, podiatrists, therapeutic optometrist. Additionally, as required by Texas Government Code § 533.0064, PCHP allows applicant practitioners to provide services to members on a provisional basis for the following provider types: Licensed Clinical Social Workers, Licensed Professional Counselors, Licensed Marriage and Family Therapists, and Psychologists. To qualify for expedited credentialing the practitioners must: 1) Be a member of an established health care provider group that has a current contract in place with PCHP, 2) Be Medicaid enrolled, 3) Agree to comply with the terms of the contract between PCHP and the health care provider group, and 4) Timely submit all documentation and information required by PCHP as necessary for PCHP to begin the credentialing process. If the practitioner qualifies for expedited credentialing, PCHP will consider the practitioner as a Network Provider upon submission of a complete application. The claims system will process claims from the practitioner no later than 30-days after receipt of a complete application.
At least once every 36-months, PCHP will review the credentials of all licensed practitioners that are participating in PCHP provider network. In addition to credentialing standards, the process will also evaluate provider performance data including member complaints and appeals, quality of care and utilization management data.
A practitioner is considered to be credentialed as of the Credentialing Committee or Chief Medical Officer decision date.
Initial credentialing decision:
- Approval or denial of initial credentialing is communicated in writing to the practitioner within 90 calendar days of receipt of a completed application.
- Appeal right is not afforded to denial of Initial credentialing.
- When initial credentialing is denied, the applicant may re-apply after one year of the denial decision date.
- PCHP is not required to provide written notification of recredentialing approval.
- PCHP will provide written notification of recredentialing denial/termination decision to the practitioner along with PCHP’s appeals process.
- Providers are required to notify us of a change in address or practice status within 10 days of the effective date of the change. Practice status is defined as a change in office hours, panel status, etc. The inclusion of a new address on a recredentialing application is not an acceptable form of notification. A notice of termination must adhere to the advance notice timelines stated in the provider’s agreement.
To submit information changes or updates, thoroughly complete the
- If you need assistance with your credentialing application status, email PCHP.Credentialing@phhs.org.