Criteria and Credentialing
It is a pleasure to provide you with information regarding Mount Carmel Health Partners. Mount Carmel Health Partners LLC has been formed to develop a Clinically Integrated provider-driven network for the purpose of providing high quality and cost efficient health care services to patients.
It is the policy of Mount Carmel Health Partners that healthcare practitioners meeting the established criteria for membership may be considered without discrimination on an equal opportunity basis without regard to an applicant's race, color, ethnic/national identity, ancestry, gender, age, sexual orientation, religion, disability, military status, genetic information, health status or type of procedure or patient in which the provider specializes. The scope of practitioners include:
- Practitioners of Psychology
- Advanced Practice Providers (APPs): CNPs, CNSs, CNMs, CRNAs and PAs
Mount Carmel Health Partners is participating in managed care agreements; including MediGold and Trinity Health Associate Health Plan at Mount Carmel Health System. Find the full list of payor contracts here. You will have the opportunity to accept or reject participation in each contract. At no time are you obligated to accept a payor contract.
The following are eligibility criteria for membership:
- A current, valid license to practice medicine/dentistry/psychology in the state of Ohio.
- Except as disclosed in writing to and accepted by the Mount Carmel Health Partners Credentialing Committee, has never been reprimanded, sanctioned, or disciplined by any licensing board or state or local medical/professional society or specialty board and his/her license/certification/registration for the practice of his/her health care profession in any state has never been suspended or revoked.
- Current federal DEA registration and Ohio controlled substance license (if applicable).
- Education and training: Successful completion of an approved postgraduate training program in the specialty in which he/she is practicing after completion of professional degree. APPs must meet training requirements set forth by their respective discipline.
- Current board certification by the appropriate specialty Board, American Board of Medical Specialties (ABMS), American Osteopathic Board (AOA), American Board of Dentistry, American Board ofPodiatric Medicine (ABPM), American Board of Foot and Ankle Surgeons (ABFAS), American Board of Oral and Maxillofacial Surgeons, National Commission on Certification of Physician Assistants (NCCPA), certification board approved by the Ohio Board of Nursing, or proof that you have met the requirements for examination for certification by the respective specialty Board. Board certification must be attained within the timeframe set by each member board not to exceed 7 years from the completion of residency training. Once attained, all specialties must maintain Board Certification and MOC/OCC requirements as specified by the respective board. Board Certification exception criteria may be referenced in Policy CR1 Credentialing Policies page 5 and 6.
- Current, valid professional liability insurance coverage in the amounts of 1M/3M.
- Except as disclosed in writing to and accepted by Health Partners Credentialing Committee, the practitioner has not had entered against it/him/her a final judgement in a malpractice action based on an allegation of malpractice nor had any action based on any allegation of malpractice settled by payment to a plantiff of an aggregate of more than One Hundred Thousand Dollars (100,000).
- Except as disclosed in writing to and accepted by the Health Partners Credentialing Committee, has not been the subject of any report or disclosure submitted to the National Practitioners Data Bank.
- Mount Carmel Health Partners does not enroll a practitioner for membership with a record of conviction of, Medicare, Medicaid, or insurance fraud and abuse, or exclusion/sanction from such programs. Health Partners does not enroll a practitioner for membership that has opted-out of Medicare (Medicare Opt Out (Part B) participation.
The Practitioner has never been debarred, suspended, declared ineligible or excluded from Medicare, Medicaid or other governmental health care programs and no material exists between it/him/her and Medicare, Medicaid or other government health care programs that could result in debarment, suspension, ineligibility or exclusion from said programs. Further, has never been convicted of a health care related criminal offense.
- Hospital Affiliation – Each Participating Practitioner (Allied Health Practitioners and Physicians) must hold current and unrestricted allied health or medical staff (as applicable) privileges at one or more Participating Hospitals unless one of the following exceptions applies:
- The Participating Practitioner does note treat his/her patients in the hospital in-patient or hospital outpatient setting; and/or
- The Participating Practitioner's primary medical practice location is outside of Franklin County, that is, more than 75% of the Participating Practitioner's patient contact hours occur at a location(s) outside of Franklin County; or
- The Participating Practitioner is a Participating Physician whose specialty is pediatrics and he/she is employed by, or contracted through, Partners for Kids. Any Participating Practitioner that falls within the second exception above must hold current and unrestricted allied health or medical staff (as applicable) privileges at a hospital located in the same county as his/her primary medical practice location, unless such Participating Practitioner does not treat patients in a hospital in-patient, hospital outpatient setting.
- All Practitioners (MDs, DOs, DPMs, DMD/DDS) with or without a hospital affiliation must provide a network cross- coverage designee or arrangements for inpatient admissions. This information is obtained from the CAQH or from the applicant. Coverage by a hospitalist group at a local hospital is acceptable coverage.
- Except as disclosed in writing to and accepted by the Health Partners Credentialing Committee, the practitioner has never been denied membership or reappointment of membership on the medical staff or allied health staff of any hospital, and no hospital medical staff or allied health staff membership or clinical privileges of Physician/Advanced Practice Provider has ever been suspended, curtailed, or revoked.
- Work History- Practitioner CAQH application and/or CV must provide at minimum the most recent five (5) years of professional work history in month/year format. Applicants with fewer than 5 years' work history; the timeframe starts at the initial licensure date. Any gap greater than 3 months must be accounted for by applicant with the initial application. Any gap greater than (1) year must be clarified in writing by the applicant with the initial application. Work history will be reviewed at recredentialing to detect any change in a practitioner's practice information.
- For each Participating Advanced Practice Provider, be:
- Employed by, or contracted with, MCHS, a Participating Physician, or a Participating Physician's medical practice; or
- In the case of a PA, have a valid supervision agreement in force with the State of Ohio Medical Board and with a Participating Provider, or
- In the case of an advanced practice registered nurse who is a CNP, CNS, or CNM, have a valid standard care arrangement in place with a collaborating Participating Provider or in the case of a CRNA have a supervising provider that is a Participating Provider.
- Current Council for Affordable Quality Healthcare (CAQH) application must be on file with CAQH Proview with a current attestation within the past 30 days. Please ensure Mount Carmel Health Partners and Mount Carmel Health System, if applicable is added to your list of affiliated plans. You can find information on the CAQH application process at www.caqhproview.org.
In order to become a member of Mount Carmel Health Partners, you must submit a completed CAQH application and complete the Health Partners credentialing approval process. The eligibility criteria listed above and the credentialing items referred to on the checklist are considered, in their entirety, your application.
Membership and Contractual Requirements
A Participating Provider Agreement, MA Addendum, if applicable documents and contracted payor requirements must be completed prior to active participation in the network; this includes the applicable credentialing fee.
For each Participating Physician, not have his/her primary medical practice (that is, more than 75% of his/her patient contact hours) through employment by, or through an independent contractor arrangement with, an individual or entity that is in direct competition with PHO or MCHS, subject to the exception described below. Physicians who have their primary medical practice though employment by, or through an independent contractor arrangement with, an entity or individual that is in direct competition with PHO or MCHS but who provide care to MCHS patients pursuant to contracted arrangement with MCHS or its affiliate or whose practice specialty has been identified as a network need (based on PHO's identification of current lack of specialties /service areas which includes ratification by the Board of Directors), shall be exempt from the foregoing requirement only for services within the scope of said contract or need.
Mount Carmel Health Partners’ Clinical Integration Program (CI) is an ongoing program to evaluate and modify practice patterns to control costs and ensure quality. Physicians participating in the program will adopt and use clinical protocols based upon evidence-based practice guidelines, and coordinate treatment and share CI information among CI physicians. Physicians will have the opportunity to participate in all Mount Carmel Health Partner’s CI Customer Agreements. APPs collaborating with a network physician participating in CI will be automatically be enrolled into the CI program.
The Mount Carmel Health Partners Credentialing Department and Provider Engagement Team is available to assist with any credentialing or payor contracting question you may have at any time.