Credentialing

Credentialing is the administrative process for validating the qualifications of licensed professionals and appraising their background. It is used by hospitals and other health care facilities, educational institutions, and insurance companies to ensure the qualification of their clinicians and to grant privileges to provide specific services and perform different medical or dental procedures. This article familiarizes the reader with the credentialing process and the documentation that is needed to be credentialed by certain organizations.

Credentialing is the administrative process for validating the qualifications of licensed professionals and appraising their background. The process generally involves an objective evaluation of a subject’s current licensure, training or experience, competence, and ability to provide particular services or perform particular procedures. It is used by hospitals and other health care facilities, educational institutions, and insurance companies to ensure the qualification of their clinicians and to grant privileges to provide specific services and perform different medical or dental procedures. The process is also used by state dental boards to grant licensure or to decide on whether to accept candidates from other states or jurisdictions for licensure by qualifications only. This article familiarizes the reader with the credentialing process and reviews documentation that is needed to be credentialed by certain organizations.

Standard credentialing information that generally is required after graduation from dental school includes the following:

  • Biographic information

  • Dental practice information

  • Current state dental license

  • Current Drug Enforcement Administration (DEA) certificate

  • Current state controlled substance certification

  • Malpractice coverage summary

  • Specialty verification

  • Board eligibility or certification verification

  • National Practitioner Data Bank (NPDB) report

The credentialing process involves initial data gathering, primary source verification, and enhanced data gathering and verification.

Initial data gathering

Initial data gathering is the process of securing a complete application with demographic information and professional credentials. It may be done by an individual institution or a network, the credentialing or peer review department of an insurance company, a professional credentialing specialist, or a regional electronic service. All questions on the credentialing application must be answered. Failure to answer all questions or to provide all requested documentation would force the credentialing committee to withdraw the dentist’s application. Similarly, information provided by the dentist must be held in the strictest confidence.

Primary source verification

Primary source verification is the process of authenticating information provided by the dentist during the initial data gathering. Dentists practicing within a community must comply with all applicable local, state, and federal laws and regulations. This compliance will vary by states or territories and, in addition to state license, may include matters related to disease and infection control, child abuse and domestic violence, infected waste material, and so on. Hospitals also have specific and unique requirements for practicing within their confines. Credentialing committees verify compliance with the necessary regulations for their region and organization. Some of the verification may be done by direct interaction with sources such as state dental boards and the NPDB via secure Internet and digital technologies or by the dentist providing proof such as malpractice certification, basis life support (BLS) or advanced cardiac life support (ACLS) cards, and proof of taking an infection control course. Primary source verification includes all or several of the items discussed in the following sections.

State licensure

A photocopy of a current state dental license (with the license number and issue date) is always requested. This copy is kept on file along with proof of current registration. The credentialing committee or department will validate that the dentist’s license to practice is active and unencumbered and will confirm whether there are any sanctions against the license. This information can be obtained directly from individual state licensing boards of dentistry.

National practitioner data bank query

The NPDB is a clearinghouse of information relating to medical malpractice payments and adverse actions taken against physicians, dentists, and other licensed health care practitioners in regards to restrictions or limitations of clinical privileges and sanctions by professional associations. Hospitals and other health care entities, including professional societies and state licensing boards, use the information contained in the NPDB in conjunction with information from other sources when granting clinical privileges or in employment, affiliation, or licensure decisions.

The information on the professional competence and conduct of physicians and dentists that is provided by the NPDB is only available to state licensing boards, hospitals and other health care entities, professional societies, certain federal agencies, and other entities specifically named under section 11134(b) of The Health Care Quality Improvement Act of 1986. Hospitals are the only health care entity with federal mandatory requirements for querying the NPDB. Information is not available to the general public, and practitioners may query the NPDB regarding themselves at any time. Several commercial dental insurance companies state on their Web page that they use information from the NPDB when considering participation on their provider panels. Health maintenance organizations (HMOs) that are entering into an affiliation relationship with a dentist who has applied for affiliation may access the information and are mandated to do so in certain localities.

The purpose of the NPDB is to improve the quality of health care by encouraging state licensing boards, hospitals and other health care entities (including insurance companies), and professional societies to identify and discipline persons who engage in unprofessional behavior and to restrict the ability of incompetent physicians, dentists, and other health care practitioners to move from state to state without disclosure or discovery of previous medical malpractice payment and adverse action history. Adverse actions can involve licensure, denial or withdrawal of clinical privileges, expulsion from membership in a professional society, and exclusions from Medicare and Medicaid.

National technical information service

A photocopy of a current DEA certificate will be requested. Validation of the practitioner’s license to prescribe drugs is done through the National Technical Information Service (NTIS). The NTIS is an agency in the Technology Administration of the US Department of Commerce that serves as the US government repository for results of research and development and for other information produced by and for the government as well as a variety of public and private sources. One of the products available from the NTIS is the complete official DEA database of persons and organizations certified to prescribe or handle controlled substances under the Controlled Substances Act. The DEA authorizes the use of this database and the inclusion of any individual or organization in the database as proof of that entity’s registration with the DEA.

General anesthesia permit (if applicable)

Validation of the practitioner’s permit to administer anesthesia is required. A photocopy of the certification for general anesthesia or conscious sedation permit is required if the applicant wishes to use sedation within a hospital or bill for sedation in a private office. Most states require additional permits or licenses for dentists who are trained in the administration of substances that produce general anesthesia, deep sedation, or conscious sedation, or for nitrous oxide sedation in patients being treated by the licensee, although most states omit nitrous oxide. The American Dental Association (ADA) position statement on the use of conscious sedation, deep sedation, and general anesthesia in dentistry advocates that state dental boards have a responsibility to ensure that only dentists who are properly trained, experienced, and competent are allowed to use conscious sedation, deep sedation, and general anesthesia within their jurisdictions .

Malpractice insurance

Current active malpractice coverage is one of the credentialing standards set by nearly all nongovernmental organizations and dental insurance companies, and this information is routinely collected as part of the process. This verification usually requires a photocopy of the current malpractice insurance certificate (with the policy number, levels of individual aggregate coverage, and dates of coverage) or a verification from the insurance carrier itself. Most organizations want an assurance that the dentist carries adequate malpractice insurance, usually $1,000,000 per occurrence and $3,000,000 per aggregate.

Specialty certification

To obtain a specialty license, to practice as a specialist within a hospital or an academic institution, or to bill an insurance carrier as a specialist, proof of specialty training is required. To become a specialist, one must be trained in a residency or advanced graduate training program accredited by the ADA. Once the residency is completed, the doctor is granted a certificate of specialty training. Many specialty programs require advanced degrees such as MD (specific to oral and maxillofacial surgery), MS, or PhD.

There are nine recognized dental specialties in the United States : dental public health, endodontics, oral and maxillofacial pathology, oral and maxillofacial radiology, oral and maxillofacial surgery, orthodontics and dentofacial orthopedics, pediatric dentistry, periodontics, and prosthodontics.

Dentists who receive formal education in these fields are designated as being “board eligible” and can advertise exclusive titles such as orthodontist, oral and maxillofacial surgeon, endodontist, pedodontist, periodontist, or prosthodontist and are educationally eligible to sit examinations to become “board certified.” Many insurance companies require board certification after a specific time to remain listed as a specialist on their panels. Hospitals also require board certification.

The specialist designations are registrable titles and in the United States are controlled by the ADA. The Dental Practice Act of most states forbids a licensed and registered dentist to designate in any manner that he or she has limited their practice to one of the specialty areas of dentistry expressly approved by the ADA unless such dentist has completed the required advanced or postgraduate education in the area of such specialty. Some states issue a specialty license or require notification of the state’s dental commission of such limitation of practice. Pseudo-specialists such as a cosmetic dentist, dental implantologist, or temporomandibular joint specialist are not fields that people are generally credentialed in as a specialist, and there are restrictions on allowing these dentists to call themselves specialists in these fields in certain jurisdictions and by some local dental associations. General practitioners can provide services in specialty areas such as oral surgery, endodontics, or periodontics, but they cannot bill as a specialist and may not receive reimbursement at the specialist fees.

Medicaid

Dental Medicaid is fairly limited, and the number of dentists participating in the program is decreasing. Some private insurance carriers, HMOs, and hospitals may try to determine whether sanctions have been imposed on the practitioner by the federal government’s Office of Inspector General or Office of Personnel Management. Exclusion for cause by Medicaid may be used by an insurance company to deny an applicant participation on their closed panel.

Primary source verification

Primary source verification is the process of authenticating information provided by the dentist during the initial data gathering. Dentists practicing within a community must comply with all applicable local, state, and federal laws and regulations. This compliance will vary by states or territories and, in addition to state license, may include matters related to disease and infection control, child abuse and domestic violence, infected waste material, and so on. Hospitals also have specific and unique requirements for practicing within their confines. Credentialing committees verify compliance with the necessary regulations for their region and organization. Some of the verification may be done by direct interaction with sources such as state dental boards and the NPDB via secure Internet and digital technologies or by the dentist providing proof such as malpractice certification, basis life support (BLS) or advanced cardiac life support (ACLS) cards, and proof of taking an infection control course. Primary source verification includes all or several of the items discussed in the following sections.

State licensure

A photocopy of a current state dental license (with the license number and issue date) is always requested. This copy is kept on file along with proof of current registration. The credentialing committee or department will validate that the dentist’s license to practice is active and unencumbered and will confirm whether there are any sanctions against the license. This information can be obtained directly from individual state licensing boards of dentistry.

National practitioner data bank query

The NPDB is a clearinghouse of information relating to medical malpractice payments and adverse actions taken against physicians, dentists, and other licensed health care practitioners in regards to restrictions or limitations of clinical privileges and sanctions by professional associations. Hospitals and other health care entities, including professional societies and state licensing boards, use the information contained in the NPDB in conjunction with information from other sources when granting clinical privileges or in employment, affiliation, or licensure decisions.

The information on the professional competence and conduct of physicians and dentists that is provided by the NPDB is only available to state licensing boards, hospitals and other health care entities, professional societies, certain federal agencies, and other entities specifically named under section 11134(b) of The Health Care Quality Improvement Act of 1986. Hospitals are the only health care entity with federal mandatory requirements for querying the NPDB. Information is not available to the general public, and practitioners may query the NPDB regarding themselves at any time. Several commercial dental insurance companies state on their Web page that they use information from the NPDB when considering participation on their provider panels. Health maintenance organizations (HMOs) that are entering into an affiliation relationship with a dentist who has applied for affiliation may access the information and are mandated to do so in certain localities.

The purpose of the NPDB is to improve the quality of health care by encouraging state licensing boards, hospitals and other health care entities (including insurance companies), and professional societies to identify and discipline persons who engage in unprofessional behavior and to restrict the ability of incompetent physicians, dentists, and other health care practitioners to move from state to state without disclosure or discovery of previous medical malpractice payment and adverse action history. Adverse actions can involve licensure, denial or withdrawal of clinical privileges, expulsion from membership in a professional society, and exclusions from Medicare and Medicaid.

National technical information service

A photocopy of a current DEA certificate will be requested. Validation of the practitioner’s license to prescribe drugs is done through the National Technical Information Service (NTIS). The NTIS is an agency in the Technology Administration of the US Department of Commerce that serves as the US government repository for results of research and development and for other information produced by and for the government as well as a variety of public and private sources. One of the products available from the NTIS is the complete official DEA database of persons and organizations certified to prescribe or handle controlled substances under the Controlled Substances Act. The DEA authorizes the use of this database and the inclusion of any individual or organization in the database as proof of that entity’s registration with the DEA.

General anesthesia permit (if applicable)

Validation of the practitioner’s permit to administer anesthesia is required. A photocopy of the certification for general anesthesia or conscious sedation permit is required if the applicant wishes to use sedation within a hospital or bill for sedation in a private office. Most states require additional permits or licenses for dentists who are trained in the administration of substances that produce general anesthesia, deep sedation, or conscious sedation, or for nitrous oxide sedation in patients being treated by the licensee, although most states omit nitrous oxide. The American Dental Association (ADA) position statement on the use of conscious sedation, deep sedation, and general anesthesia in dentistry advocates that state dental boards have a responsibility to ensure that only dentists who are properly trained, experienced, and competent are allowed to use conscious sedation, deep sedation, and general anesthesia within their jurisdictions .

Malpractice insurance

Current active malpractice coverage is one of the credentialing standards set by nearly all nongovernmental organizations and dental insurance companies, and this information is routinely collected as part of the process. This verification usually requires a photocopy of the current malpractice insurance certificate (with the policy number, levels of individual aggregate coverage, and dates of coverage) or a verification from the insurance carrier itself. Most organizations want an assurance that the dentist carries adequate malpractice insurance, usually $1,000,000 per occurrence and $3,000,000 per aggregate.

Specialty certification

To obtain a specialty license, to practice as a specialist within a hospital or an academic institution, or to bill an insurance carrier as a specialist, proof of specialty training is required. To become a specialist, one must be trained in a residency or advanced graduate training program accredited by the ADA. Once the residency is completed, the doctor is granted a certificate of specialty training. Many specialty programs require advanced degrees such as MD (specific to oral and maxillofacial surgery), MS, or PhD.

There are nine recognized dental specialties in the United States : dental public health, endodontics, oral and maxillofacial pathology, oral and maxillofacial radiology, oral and maxillofacial surgery, orthodontics and dentofacial orthopedics, pediatric dentistry, periodontics, and prosthodontics.

Dentists who receive formal education in these fields are designated as being “board eligible” and can advertise exclusive titles such as orthodontist, oral and maxillofacial surgeon, endodontist, pedodontist, periodontist, or prosthodontist and are educationally eligible to sit examinations to become “board certified.” Many insurance companies require board certification after a specific time to remain listed as a specialist on their panels. Hospitals also require board certification.

The specialist designations are registrable titles and in the United States are controlled by the ADA. The Dental Practice Act of most states forbids a licensed and registered dentist to designate in any manner that he or she has limited their practice to one of the specialty areas of dentistry expressly approved by the ADA unless such dentist has completed the required advanced or postgraduate education in the area of such specialty. Some states issue a specialty license or require notification of the state’s dental commission of such limitation of practice. Pseudo-specialists such as a cosmetic dentist, dental implantologist, or temporomandibular joint specialist are not fields that people are generally credentialed in as a specialist, and there are restrictions on allowing these dentists to call themselves specialists in these fields in certain jurisdictions and by some local dental associations. General practitioners can provide services in specialty areas such as oral surgery, endodontics, or periodontics, but they cannot bill as a specialist and may not receive reimbursement at the specialist fees.

Medicaid

Dental Medicaid is fairly limited, and the number of dentists participating in the program is decreasing. Some private insurance carriers, HMOs, and hospitals may try to determine whether sanctions have been imposed on the practitioner by the federal government’s Office of Inspector General or Office of Personnel Management. Exclusion for cause by Medicaid may be used by an insurance company to deny an applicant participation on their closed panel.

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Oct 29, 2016 | Posted by in General Dentistry | Comments Off on Credentialing
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