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HFNI Credentialing Requirement Changes for 2012

February 10, 2012

There are several additional provider requirements now required by Federal and State statutes that HFNI will be asking Providers to meet beginning in January of 2012. Several standards pertain to language and wording in physician contracts and subcontract provisions. The Credentialing standards will apply for all Providers submitting new initial credentialing applications to Health First Network and for all HFNI Providers submitting re-credentialing applications. These requirements are mandated by AHCA contracts and/or Federal Law. Compliance with these statutes is not optional.

Simply stated, because Health First Network Physicians care for beneficiaries covered under both Medicaid and Medicare Advantage Programs, Health First Network, Inc., is required to comply with all applicable federal and state laws, regulations and CMS instructions pursuant to statutes listed in these federal and state regulations. Some of these contract provisions were not a standard part of HFNI Provider contracts. Health First Network submitted these to our Corporate Attorney for review and recommendations. Recommendations have been received back and are under review for inclusion in HFNI Joinders. For credentialing standards, there are three disclosure requirements required by law that are bundled together. These three disclosure requirements have to do with: ( A) ownership and management; (B) business transactions; and (C) Crimes related to any Provider’s involvement in any program under Medicare, Medicaid, or the title XX program since the inception of those programs.

In order to comply with Federal Law (42 CFR 420.200-420.206 and 455.100-455.106) and Medicaid Program Integrity requirements, health plans and Provider Organizations with Medicaid or Medicare business are required to obtain information regarding the ownership and control of entities with which the health plan or provider network contracts for services for which payment is made under the Medicaid or Medicare Program or any line of business that provides healthcare for federal employees. The Centers for Medicaid and Medicare Services (CMS) require Health First Network, Inc., and its subsidiaries to obtain this information to demonstrate that Health First Network is not contracting with an entity that has been excluded from federal health programs, or with an entity that is owned or controlled by an individual who has been convicted of a criminal offense, has had civil monetary penalties imposed against them, or has been excluded from participation in Medicare or Medicaid.

A form related to this these issues will be included in application packets for initial credentialing applications and re-credentialing packets. A copy of this form is attached below.

Provider and Subcontractor Ownership/Controlling Interest Worksheet

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