Contracting Guidelines

Participation and Credentialing Standards

Statement of Purpose
The following criteria apply to each participating imaging provider in the MedSolutions Imaging Network (Network), and shall be enforced at the discretion of MedSolutions. MedSolutions will credential participating imaging providers to these criteria or adopt the credentialing standards of payers contracted with MedSolutions and/or the Network. All imaging providers must continue to meet the credentialing standards for the duration of participation in the Network.

The Network Credentialing Committee is responsible for the credentialing of imaging providers for Network membership. The Committee is comprised of representatives from Network Development, Quality Management, Operations, and the Network Medical Director (Chairperson). The Committee will meet at least quarterly and/or as needed. Responsibilities include the following:

• To develop and recommend criteria for membership
• To evaluate and recommend the acceptance, deferment, or rejection of all member applicants based on approved criteria
• To annually review and evaluate the membership prerequisites and criteria for acceptance, the criteria for panel participation, and the criteria for the termination of a member and recommend appropriate changes

The Committee will process and review applications within 180 days of receiving a completed application from the applicant. A majority vote of the members present at a Committee meeting shall be the act of the Credentialing Committee.

Statement of Confidentiality
Individuals engaged in credentialing activities shall maintain the confidentiality of the information with which they deal. In particular, information supplied by the applicant in the application will remain confidential.

The Committee will maintain copies of all minutes, applications, reports, work sheets, and other data in a manner to ensure confidentiality and restrict access only to Committee members and those specific individuals designated the Chairperson.

Conflict of Interest
No person may participate in the review and evaluation of any application in which he/she has been professionally involved or where his/her judgment may be compromised.

Participation Criteria
For Network participation, verification of the following credentials is required:

• For free-standing diagnostic radiology facilities, current accreditation by the American College of Radiology (ACR) or the American Institute of Ultrasound in Medicine (AIUM) for appropriate modalities
• For hospital-based imaging facilities or hospital associated mobile imaging services, current JCAHO accreditation
• For Radiologists, current Board Certification in Radiology by the American Board of Radiology (ABR)
• Physicians who provide professional interpretation of nu8clear medicine studies must be board certified in Diagnostic Radiology, Nuclear Medicine or Cardiology as appropriate to the type of services they provide. In addition, physicians who interpret PET studies should have additional training qualifications specific to PET. 

Contractual Obligations
In order to continue unrestricted participation in the Network, Providers are contractually obligated to meet the following quality requirements:

• Maintain appropriate licensure and certification required by regulatory organizations
• If applicable, Technologists will maintain relevant agency and state licensure
• Maintain general and professional liability insurance at a minimum of $1,000,000 for each individual claim and $3,000,000 or such other amounts that may be required or approved by MedSolutions in the aggregate for each year
• With appropriate notice, provider will furnish requested film and/or imaging reproductions and/or records and reports relating to examinations, patients, or other Network concerns
• If necessary and with agreeable advance notice, the provider will consent to an on-site visit which may include authorized MedSolutions representative or authorized designee(s) observing the facility during normal business hours, the review of requested film and/or image reproductions, records and reports relating to patients, or other Network concerns
• Provide direct notification to MedSolutions of any condition that restricts their ability to provide imaging services (for example, Medicare and/or Medicaid sanctions, loss of state health certificate, loss of accreditations or certifications, etc.)
• Disclose all licensure actions, limitations, terminations or voluntary relinquishment of licenses in any state, participation in Medicare, Medicaid, or other governmental programs, or certification, accreditation or other authorization required by law or the Agreement to provide imaging services
• Relevant facility staff will undergo an orientation program and ongoing in-service training as necessary including, but not limited to, new technology or new types of diagnostic imaging studies, radiation safety and CPR/advanced life support
• Obtain written consent from MedSolutions prior to delegating Facility services to other parties
• Agree to see new patients under Network Payer contracts on the same basis and in accordance with the same standards of timeliness and care offered to all other patients of the imaging provider
• Cooperate in Network-approved UM and Quality programs
• Update, within 30 days, all information provided on the application in the event that any information disclosed changes

The Committee will approve any exceptions prior to participation. The Credentialing Committee may waive any qualification for participation upon determination that such waiver is in the interest of good medical practice and the provision of quality of care. This shall be done on an individual basis.

Based on the initial application review, MedSolutions may grant the facility provisional membership for 180 days pending credentials verification and/or successful completion of the Participation Assessment process.

Credentialing Process
The Network will obtain verification of the following information and certificates within 180 days of the receipt of any application:

• Applicable Accreditations and/or Board Certifications: ACR, AIUM, JCAHO, Board Certification
• W9
• State license certificate
• Proof of general and professional liability insurance
• MQSA certification (if applicable)

Through a partnership with an NCQA and URAC accredited Credential Verification Organization, MedSolutions may implement primary source verification using NCQA standards.

Participation Assessment
If an imaging provider does not meet the participation criteria, the Network may initiate an evaluation of imaging services reviewing technical performance equipment, staffing, professional services, and patient safety and convenience. The Credentialing Committee will consider all applications on a case-by-case basis. Successful completion of the Assessment is required within 180 days for Network credentialing acceptance.

Appeal Process
In the event a provider is denied participation in the Network based on technical performance measures or quality of care issues, the provider may request an appeal hearing by sending a written request to the committee chairman. A committee of peers selected from current Medsolutions Physician Advisors will review the appeal and make a recommendation to the Credentialing Committee. The Credentialing Committee will issue a decision based on a positive recommendation. In seeking reconsideration, the Committee may request new or additional information from the applicant to support the request for participation. The appeals process will be completed within 30 days from the date of the request for reconsideration was received.

The decision of the Committee upon reconsideration is final. In the event that the application is denied membership upon reconsideration, the Facility may reapply within one year from the appeal decision of the Committee.

An applicant who has questions concerning decisions made by the Credentialing Committee regarding participation status may direct questions to the current Network Medical Director.

Recredentialing
Recredentialing for Network members shall occur every two years. Criteria for recredentialing review will be identical to Participation Criteria with the exception of the addition of a review of member complaints, results of quality reviews, utilization management, and member satisfaction surveys when available.

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