UNIVERSITY OF HOUSTON



university of houston

COLLEGE OF OPTOMETRY

University eye institute

CLINIC BUSINESS OFFICE • Policy 31.0

February 15, 2008

UEI Credentialing Procedures

I. INTRODUCTION

▪ For over 50 years, UHCO has distinguished itself as a leader in optometric education, vision research, patient care and community service. Whether considering a career in the profession, seeking information on eye and vision disorders or requesting an appointment at the University Eye Institute, UH College of Optometry is an unrivaled choice.

▪ In May, 2003, the Houston Business Journal listed the University Eye Institute (UEI) as the 7th largest outpatient health facility in Houston. The UEI at UHCO serves more than 30,000 patients each year and is equipped with the latest ophthalmic instruments and diagnostic systems.

▪ Additionally, there is a full service optical dispensary at the University Eye Institute with certified opticians to provide selection, fitting, and dispensing of eye wear.

▪ Clinical Services at the University Eye Institute include:

- Family Practice Service

- Cornea and Contact Lens Service

- Specialty Pediatrics and Binocular Vision Service

- Ocular Diagnostics and Medical Eye Service

- Center for Sight Enhancement

The University Eye Institute Credentialing Plan provides written standards and guidelines for the selection, evaluation and continuous quality monitoring of its Members. This Plan seeks to establish compliance with the National Committee for Quality Assurance (NCQA) Physician Organization Standards for credentialing, re-credentialing and other related functions. The University Eye Institute participates in the National Practitioner Data Bank (NPDB) and complies with the regulations established by the NPDB, the Texas Medical Practice Act, The Texas Optometry Act, the Contact Lens Prescription Act, the Health Care Quality Improvement Act and other applicable laws and regulations.

II. PURPOSE OF THE CREDENTIALING PROGRAM

The University Eye Institute Credentialing Program purposes are:

▪ The development of credentialing, re-credentialing and related policy and procedure;

▪ The systematic and objective evaluation and selection of its Members;

▪ The continuous monitoring and disciplining of its Members for compliance with participation and patient care standards;

▪ Providing reliable demographic, credentialing, performance monitoring and other information to the managed care organizations and payors with whom it contracts; and

▪ The ongoing evaluation of the effectiveness of the Program.

The University Eye Institute Credentialing and Privileging Committee may develop other components to the Program in order to meet the objectives of the Department.

III. DEFINITIONS

For the purpose of the University Eye Institute Credentialing Plan, the following definitions apply:

Applicant: The term Applicant refers to a practitioner who has been identified by the Medical Director / Executive Director as eligible for participation in the University Eye Institute and has submitted an Application for Appointment.

Allied Health Professional: A licensed/certified health professional other than a Physician, or Optometrist who satisfies the credentialing and employment requirements.

Advisory Committee: The term Advisory Committee refers to the University Eye Institute Doctor Members who develop policy and procedure and monitor all aspects of the Services, it members and employees.

Committee: The term Committee refers to the University Eye Institute Credentialing and Privileging Committee.

Credentialing Staff: The term Credentialing Staff is inclusive of all employees, agents, and contracted personnel who work for or on behalf of the University Eye Institute Managed Care Department.

Member: The term Member refers to a practitioner who has sought and successfully obtained appointment and continued re-appointment to the University Eye Institute.

Non-Adverse Corrective Action: An informal means of gathering information and communicating to the Member, practitioner, or Allied Health Professional areas of concern.

Patient: A patient is an individual who seeks health care services from the University Eye Institute Members either independently or through enrollment with a University Eye Institute Payor.

Payor: A payor is a managed care organization (MCO) or other third party with whom the University Eye Institute has contracted for the provision of health care services.

Peer Review: An unbiased evaluation by a group or committee of professional peers whose charge is to evaluate the clinical competence and credentials for initial or continuing membership or as part of an ongoing monitoring or appraisal process.

Performance Improvement: An approach to the continuous study, analysis and improvement of the processes and outcomes of providing health care services to meet the needs of the patient(s).

Plan: The term Plan refers to the University Eye Institute Credentialing Plan and the standards, policy and provisions contained within.

Practitioner: A practitioner is a duly licensed physician, optometrist, or allied health professional who provides or participates in the provision of health care services.

Primary Source Verification: The process in which credentialing information from the organization that originally conferred the credentialing information is validated.

Program: The term Program refers to the University Eye Institute Credentialing Program and is inclusive of all credentialing, re-credentialing and related activity, document(s), committee(s) and staff.

Reconsideration Review: An informal procedure that provides the Practitioner or Allied Health Professional the opportunity to supplement the documentation under review by the Credentialing Committee and/or to oppose the Credentialing Committee’s decision.

Review Designee: The entity or individual(s) authorized to serve as an agent of the Credentialing Committee to conduct a medical record(s) review of a Practitioner or Allied Health Professional.

IV: AUTHORITY AND RESPONSIBILITY

Governance

These credentialing policies and procedures govern the process by which the University of Houston, College of Optometry determines the qualifications of an individual practitioner to participate in the University Eye Institute and render care to patients. The Credentialing and Privileging Committee will consist of three UEI participating providers. The Credentialing and Privileging Committee Medical Director / Executive Director / Chairperson shall posses the authority for oversight of the University Eye Institute Credentialing Program.

Participation

Participation in the University Eye Institute is determined based on qualifications, economic factors, availability, and other considerations at the sole discretion of the University of Houston, College of Optometry. Participating providers shall sign an agreement with the University of Houston College of Optometry.

University Eye Institute Credentials and Privileging Committee

The University Eye Institute Credentials and Privileging Committee accepts responsibility from the Medical Director/Chairperson to:

• Conduct peer review of practitioners applying or re-applying for appointment to the University Eye Institute;

• Approve or deny Member appointment and re-appointment;

• In cooperation with other committees and programs, act as a peer review entity for Members who fail to comply with the terms or criteria for continued participation in related committees and programs;

• Provide an appeal process for Applicants who are denied participation or Members who are disciplined or terminated; and

• Develop and approve credentialing, re-credentialing and related policy.

The Committee consists of:

UEI Medical Director / Executive Director

Family Practice Service Director

Cornea and Contact Lens Service Director

Pediatric and Binocular Vision Service Director

Ocular Diagnostic Service Director

Low Vision Service Director

One Doctor from the General Clinical Facility

Director, UEI Clinic Business Office

UEI’s Credentialing Specialist

The Committee meets at least twice a year and reports its activity and findings, in summary, to the Dean. The Committee seeks to comply with the Health Care Quality Improvement Act, NCQA standards and applicable law. The activity of the Committee shall be confidential and is protected by applicable peer review law.

University Eye Institute Credentials Committee Chairman / UEI Medical Director / Executive Director

The University Eye Institute Credentials and Privileging Committee Chairman / UEI Medical Director / Executive Director is appointed by the Dean and is responsible for the implementation and oversight of the University Eye Institute Credentialing Program to include the following duties:

• Serve the University Eye Institute Credentials and Privileging Committee as Medical Director / Executive Director / Chairman and member;

• Provide for the administrative needs of the Committee;

• Act to interpret and clarify policy and related standards of practice;

• Enforce standards for Member participation;

• Ensure that practitioner and patient information is kept confidential;

• Oversee the application of all policy and procedure in the credentialing process; and

• Provide due process to each Applicant or Member according to policy.

A Vice-Chairman may be appointed by the Dean to act in the absence of the Chairman or at his/her request.

University Eye Institute Credentialing Specialist

The University Eye Institute Credentialing Specialist is responsible for supervising the daily credentialing, re-credentialing and related activities required to fulfill the purpose of the Program. The responsibilities of the Credentialing Specialist(s) include:

• Collecting and primary source verification of practitioner demographic and credentialing data;

• Maintaining Member files;

• Coordinating information for reporting to the University Eye Institute payors;

• Ensuring that all practitioner and patient information is kept confidential;

• Complying with NCQA and payor standards, and all applicable law and regulations regarding credentialing, re-credentialing and related activities;

• Assisting in the development of policy and procedure for approval; and

• Performing other duties as needed to comply with the University Eye Institute policy.

V. PRACTITIONER APPOINTMENT

Scope of Practitioners

The University Eye Institute may appoint the following types of practitioners as Members:

• Physicians (MD & DO)

• Optometrists (OD)

• Physician Assistants

• Advanced Practice Nurses

• Occupational Therapists

Length of Appointment

All Member appointments granted by the University Eye Institute are for a period of time not to exceed three years. At the end of each three-year appointment cycle, a Member must reapply for appointment and successfully fulfill the credentialing and other criteria established by the Committee.

Practitioner Rights

All University Eye Institute Members and Applicants are afforded basic rights in the credentialing process that include, but are not limited to, the following:

• No practitioner will be denied Member status on the basis of sex, race, creed, color, ethnic origin, age, or disability that does not affect the Applicant’s ability to practice his/her specialty.

• The University Eye Institute will not discriminate against a practitioner who specializes in high-risk or costly treatments.

• A practitioner may review information collected during the credentialing process unless otherwise protected by applicable peer review law.

• A practitioner may correct erroneous information collected during the credentialing process.

• A practitioner may provide an explanation for any substantial discrepancy found between information reported by the practitioner and information reported from another source.

• Due diligence shall be made in the verification process of each practitioner’s credentials and he/she may assist in obtaining information for verification.

• Due process is provided to any Member who is denied re-appointment or who is the subject of a disciplinary action on the basis of professional conduct, competence, or quality of care.

• Other rights as required by applicable law shall be afforded to the practitioner.

Applicants and Members are notified of their rights in writing at the time of application for appointment, re-appointment, and other such times when a practitioner may have cause to invoke these rights.

Provisions of Appointment

All practitioners who are granted membership into The University Eye Institute shall agree to abide by the following stipulations for the duration of his/her appointment:

• All terms and conditions specified in this Plan;

• Continued compliance with credentialing and other criteria for participation; and

• Other provisions as set forth in the University of Houston, College of Optometry for Appointment (Texas Common Credentialing Application), the University Eye Institute Application for Re-appointment, University Eye Institute Policy and Procedure, and any Member agreement executed between a practitioner and UEI payor .

VI. CREDENTIALING CRITERIA FOR INITIAL APPOINTMENT

Initial appointment to The University Eye Institute is contingent upon successful completion of the credentialing process and faculty appointment process. An appointment is granted by the University Eye Institute Medical Director / Executive Director after an Applicant’s credentials have been considered and determined to satisfy University Eye Institute faculty appointment, credentialing, and participation criteria.

Criteria for Initial Appointment

In order to obtain an appointment to the University Eye Institute, a practitioner member must satisfy the following criteria:

a) Be identified by the Medical Director / Executive Director as eligible for participation;

b) Submit a complete, original the University Eye Institute Texas Common Credentialing Application for Appointment (attached as Exhibit A);

c) Submit clear documentation of acceptable clinical background, successful completion of education at an accredited school, acceptable work history, and ability to perform the essential functions required for the provision of medical services either with or without accommodation;

d) Submit a current work and academic curriculum vitae;

e) Submit evidence that a signed protocol exists between the practitioner and his/her supervising Member doctor if applicable to non-physicians (scope of duty);

f) Possess a current, unrestricted license to practice his/her profession in Texas;

g) Possess a current, unrestricted Drug Enforcement Administration Certificate (DEA) and a Texas Controlled Substance Registration (DPS) if applicable to profession;

h) Be certified by Medicare and Medicaid if appropriate;

i) For physicians: 1) Be certified by a specialty board which is a member of the American Board of Medical Specialties or a specialty board approved by the American Osteopathic Association, or 2) Have completed post-graduate training and be in process of fulfilling the requirements to qualify for certification examination, or 3) Meet the requirements for waiver of board certification as established by University Eye Institute;

j) For O.D.’s 1) Be currently licensed by the Texas Optometry Board.and fufill all stipulations of the University Eye Institute credentialing document for clinical attendings

k) If not board certified, submit sufficient Continuing Education units as required by appropriate licensing boards;

l) Maintain professional liability insurance coverage in the minimum amounts and terms established by the University Eye Institute and The State of Texas;

m) For MD’s only; 1) Have clinical privileges in good standing at a hospital with which a UEI payor is affiliated, or 2) Supply documentation for the lack of clinical privileges and appropriate coverage of inpatient services if applicable to profession;

n) Submit the names of three references who can attest to the practitioner’s professional competence, level of knowledge, clinical experience, training, quality of care, ethical character, and ability to work with others;

o) Be of sufficient physical and mental health to fulfill his/her professional responsibilities;

p) Have never been convicted of or plead no contest to a felony or any offense involving moral turpitude or any offense related to the practice or ability to practice medicine or the related healing arts;

q) Have no current or prior actions against his/her professional license in any jurisdiction which resulted in voluntary or involuntary probation, restriction or forfeiture;

r) Have no history of sanctions by Medicare or Medicaid authorities;

s) Have no history of probated, suspended, restricted or revoked privileges at a healthcare facility, and no history of voluntary surrender of privileges to avoid disciplinary action;

t) Be free of present illegal drug use and have no current substance abuse/chemical dependency;

u) Agree to provide 24 hours coverage to patients, either personally or through practice coverage arrangements with other University Eye Institute Members;

v) Have a satisfactory professional liability history;

w) Agree to report to the University Eye Institute within a period of ten (10) days any disciplinary action taken against the practitioner by a healthcare facility, healthcare organization, state licensing body, or Medicare/Medicaid program.

x) Consent to participate in Utilization Review and Quality Management programs including the evaluation of his/her practice site and medical records to ensure compliance with University Eye Institute standards;

y) Agree to comply with all University Eye Institute’s Policy and Procedures; and

z) Agree to comply with the terms and conditions as set forth in the Plan, University Eye Institute Application for Appointment, any agreement executed between the University Eye Institute and the practitioner, and other terms and conditions of appointment as established from time to time.

Allowable Sources of Verification

Prior to presentation of an Applicant’s credentials to the University Eye Institute Credentialing and Privileging Committee for review, the University Eye Institute Credentialing Staff obtains a mandatory report from the NPDB and the TSBME/TOB and verifies all criteria for appointment from primary or other sources. The following sources are acceptable for verification of the corresponding criteria. The information for each criterion must be verified from at least one allowable source listed unless otherwise specified. No verifications can be older than the established limits when considered by the University Eye Institute Credentialing and Privileging Committee:

|Criteria for |Allowable Source(s) |Verification |

|Initial Appointment |Of Verification |Time Limit |

|If applicable | | |

|Eligibility for Participation |Written Notice from Medical Director |None |

|Texas Professional License |TSBME/TOB |60 days, valid license |

| |Licensing Board | |

|DEA Certification |Document Copy |60 days, valid certificate |

| |NTIS | |

|DPS Registration |Document Copy |60 days, valid registration |

| |Registration Board | |

|Medicare/Medicaid Certification |Application |None |

|Board Certification |ABMS |One Year, current edition |

| |Certifying Board | |

|Professional Liability Insurance Coverage |Document Copy |60 days, valid coverage |

| |Insurance Carrier | |

|Hospital Privileges |Hospital/Facility |60 days |

|Application/Attestation/CV |Document Copy |60 days |

|Education/Training* |Medical / Optometry School |None |

| |Training Institute | |

|Work History |Application |60 days |

| |CV | |

|Professional References |Professional References (3) |None |

|Physical/Mental Health |Application |60 days |

|Criminal History |Application |60 days |

| |NPDB | |

| |Licensing Board | |

|Licensure Sanctions |Licensing Board |60 days |

|Medicare/Medicaid Sanctions** |NPDB |60 days |

| |OIG/GSA | |

|Hospital Sanctions |Hospital/Facility |60 days |

| |NPDB | |

|Substance Abuse |Application |60 days |

|24-hour Coverage |Application |None |

|Professional Liability History |Insurance Carrier |60 days |

| |NPDB | |

|Compliance with Policy |Application |None |

|Supervising Physician Protocol |Document Copy |One Year |

|Office Site Evaluation |Office Site Evaluation |Two Years |

|Medical Record Review |Medical Record Review |Two Years |

* If a practitioner is Board Certified, verification of board certification fulfills need to verify education/training. Otherwise, only highest level of education/training must be verified from the appropriate school or institute.

** Verifications or queries must be made of all sources listed.

Methods of Verification

The University Eye Institute Credentialing Staff may use oral, written, Internet or other electronic means to verify information. Oral, Internet and electronic means of verification require appropriate documentation of the verification including the date that the information was collected and the signature or the initials of the staff member collecting the information. Where document copies serve as verification, the date the document was received is required. Where information is verified from the University Eye Institute Application for Appointment, the application must include the date it was received and all required Applicant signatures.

VII. CREDENTIALING CRITERIA FOR RE-APPOINTMENT

All Member appointments granted by the University Eye Institute are for a period of time not to exceed three years. Prior to the end of each three-year appointment cycle, a Member must reapply for appointment and successfully fulfill the credentialing and other criteria established by the University Eye Institute. Re-appointment to the University Eye Institute is contingent upon successful completion of the credentialing process. Re-appointment is granted by The University Eye Institute Credentials and Privileging Committee or the Medical Director / Executive Director after a Member’s credentials have been considered and determined to satisfy the University Eye Institute credentialing and participation criteria.

Criteria for Re-Appointment

At re-appointment, a Member must meet all the criteria for initial appointment. The University Eye Institute Credentialing Staff verifies information from primary or other sources. In addition, the following data will be collected, if available:

• Patient Complaints;

• Information from the Quality Assurance Committee;

• Patient satisfaction surveys;

This information may be supplied by the Physician Metrics and Quality Management personnel. The University Eye Institute may request this information from its payors for inclusion in the re-appointment process.

Allowable Sources of Verification

Prior to presentation of a Member’s credentials to The University Eye Institute Credentials and Privileging Committee for review, the University Eye Institute Managed Care Staff obtains a mandatory report from the NPDB and the TSBME/TOB and verifies all criteria for re-appointment from primary or other sources. Only information that is subject to change over time requires verification. Static historical elements do not need to be re-verified. The following sources are acceptable for verification of the corresponding criteria. The information for each criterion must be verified from at least one allowable source listed unless otherwise specified. No verifications can be older than the established limits when considered by the Credentials and Privileging Committee:

|Criteria for |Allowable Source(s) |Verification |

|Re-appointment |Of Verification |Time Limit |

|If applicable | | |

|Texas Professional License |TSBME/TOB |60 days, valid license |

| |Licensing Board | |

|DEA Certification |Document Copy |60 days, valid certificate |

| |NTIS | |

|DPS Registration |Document Copy |60 days, valid registration |

| |Registration Board | |

|Board Certification* |ABMS |One Year, current edition |

| |Certifying Board | |

|Professional Liability Insurance Coverage |Document Copy |60 days, valid coverage |

| |Insurance Carrier | |

|Hospital Privileges |Hospital/Facility |60 days |

|Application/Attestation/CV |Document Copy |60 days |

|Physical/Mental Health |Application |60 days |

|Criminal History |Application |60 days |

| |NPDB | |

| |Licensing Board | |

|Licensure Sanctions |Licensing Board |60 days |

|Medicare/Medicaid Sanctions** |NPDB |60 days |

| |OIG/GSA | |

|Hospital Sanctions |Hospital/Facility |60 days |

| |NPDB | |

|Substance Abuse |Application |60 days |

|Professional Liability History |Insurance Carrier |60 days |

| |NPDB | |

|Supervising Physician Protocol |Document Copy |One Year |

|Office Site Evaluation |Office Site Evaluation |Two Years |

|Medical Record Review |Medical Record Review |Two Years |

* Board Certification is verified only if certification expired since last appointment cycle.

** Verifications or queries must be made of all sources listed.

Methods of Verification

The University Eye Institute Managed Care Staff may use oral, written, Internet or other electronic means to verify information. Oral, Internet and electronic means of verification require appropriate documentation of the verification including the date that the information was collected and the signature or the initials of the staff member collecting the information. Where document copies serve as verification, the date that the document was received is required. Where information is verified from the University Eye Institute Application for Re-appointment, the application must include the date it was received and all required Member signatures.

VIII. DECISIONS REGARDING APPOINTMENT/RE-APPOINTMENT

University Eye Institute Credentials Committee Decisions

The University Eye Institute Credentialing and Privileging Committee makes all appointment and re-appointment decisions within 180 days from the date of the Applicant’s original attestation statement. Should additional time be required, the Applicant must sign a statement attesting that the information contained in the University Eye Institute Application for Appointment and supporting documentation continues to be true and complete. If any element contained in the University Eye Institute Application for Appointment and supporting documentation has changed, the Applicant must sign a statement describing such changes in detail and re-attest that other elements remain true and complete.

The University Eye Institute Credentialing Staff shall provide the University Eye Institute Credentialing and Privilrging Committee with a summary of each practitioner presented for appointment or re-appointment. Each practitioner file presented to the University Eye Institute Credentialing and Privileging Committee is classified as requiring “Routine” or “Special” review. A “Routine” file contains no potential credentialing or quality issues and does not require intensive review by the Committee. A “Special” file requires intensive review by the Committee based upon potential credentialing or quality issues found during the credentialing process. These issues include, but are not limited to:

• Any malpractice action filed against the practitioner within the past five years.

• Any physician practitioner who is not Board Certified.

• Any “yes” response to questions contained in the Application for Appointment regarding physical/mental health or substance abuse/chemical dependency.

• Any past or current disciplinary actions, sanctions, or board orders.

• Any quality issues identified.

• Any other issue requiring intensive Committee review.

A recommendation regarding appointment or re-appointment is based upon the information provided by the practitioner and collected during the credentialing process. Peer review discussions and deliberations serve to facilitate a decision. These discussions are undertaken with appropriate objectivity and use all the information obtained to evaluate the practitioner against the defined credentialing criteria. In accordance with state and federal regulations, all peer review discussion and activity is confidential and protected from discovery.

A quorum of the University Eye Institute Credentialing and Privileging Committee is required to make decisions regarding appointment and re-appointment. A majority of the Committee quorum is required for all decisions. At such time when a quorum is not present, discussion may take place between at least two voting Committee members present. A summary of the discussion may be forwarded to all Committee members for a proxy vote. Proxy votes are required from a majority of the Committee to render a decision.

The University Eye Institute Credentialing and Privileging Committee may waive any appointment or re-appointment criteria. A waiver must be based upon objective consideration of the practitioner’s credentials. The Committee may not waive any criterion based upon a practitioner’s unwillingness to supply the Credentialing Staff with information or assistance in obtaining information.

Reasons for Denial of Appointment or Re-Appointment

In addition to failure to meet any of the credentialing criteria set forth in Article VI or VII, the following may be a basis for denial of appointment or re-appointment:

• The practitioner has actions against his/her professional license in any jurisdiction which resulted in probation, restriction or forfeiture or in which the practitioner voluntarily relinquished his/her professional license to avoid probation, restriction or forfeiture of his/her license.

• The practitioner fails to maintain a current license or permit to practice medicine, optometry, or his/her profession in the State of Texas.

• The practitioner has been convicted of a felony, any offense involving moral turpitude, or any offense related to the practice or the ability to practice medicine or the related healing arts, whether as a result of a guilty plea, a plea of no contest or a verdict of guilty.

• The practitioner has been expelled or suspended from the Medicare or Medicaid programs or has voluntarily resigned to avoid expulsion or suspension.

• The practitioner has engaged in malpractice, which may be evidenced by claims of malpractice settled against the practitioner, judgments of malpractice against the practitioner, a trend of malpractice actions relating to same/similar procedures, or being dropped by his/her insurance carrier.

• The practitioner fails to maintain professional liability insurance coverage in the minimum requirements required by the University Eye Institute.

• The practitioner has knowingly falsified his/her University Eye Institute Application for Appointment or Re-appointment or has made a misrepresentation or a false, misleading, inaccurate or incomplete statement in his/her application.

• The practitioner has been censured, suspended or expelled from any hospital medical staff or had his/her privileges suspended, revoked or limited or has voluntarily resigned to avoid censure, suspension or expulsion.

• The practitioner has failed to cooperate with the Quality Management or Utilization Review programs established by the University Eye Institute payors.

• The practitioner has an impairment due to chemical dependency/substance abuse that affects his/her ability to provide quality care to patients.

• The practitioner has failed to report any disciplinary actions taken against him/her.

• The practitioner fails to comply with any other University Eye Institute policy, procedure, term or condition as set forth in the University Eye Institute Application for Appointment, this Plan, any Policy and Procedure or any agreement executed between the practitioner and University Eye Institute.

• The Department Chairman does not recommend the practitioner for appointment based upon the criteria set by The University Eye Institute for eligibility.

• There is a reasonable belief that appointment or re-appointment has or could have an adverse impact on the health or welfare of University Eye Institute patients.

The University Eye Institute Credentials Committee Chairman will notify a practitioner, in writing, of the reason for denial of appointment or reappointment. A Member may appeal a denial for re-appointment that is based upon any of the foregoing grounds in accordance with University Eye Institute policy regarding appeals.

IX. CRITERIA FOR CONTINUED PARTICIPATION

University Eye Institute Members must continue to meet all credentialing and participation criteria between appointment cycles. In addition, Members are required to comply with practice standards as established by the University Eye Institute. Failure to comply with any credentialing, participation or other criteria at any time during participation may result in disciplinary action.

X. DISCIPLINARY ACTIONS/APPEALS PROCESS

Disciplinary Actions

The University Eye Institute Credentialing and Privileging Committee or the Chairman/Medical Director may take disciplinary action at any time during a Member’s appointment. Any member will be provided an opportunity in accordance with all applicable due process requirements, to address adverse decisions based upon quality of care or other peer review based determinations as listed below. All information submitted will be reviewed by Committee Members which will render a recommendation which is supported with evidence regarding educational background and training, experience, professional behavior and appropriate utilization of resources in providing high quality patient care.

Reasons for action include failure to meet the credentialing and participation criteria established by the University Eye Institute, any event listed in Article VIII, or where a reasonable belief exists that the Member’s conduct requires action. The following are examples of disciplinary actions:

• Letter of reprimand

• Letter of censure

• Letter of admonition

• Probation

• Suspension

• Termination

• Restriction of practice

• Denial of Re-appointment

In addition, the University Eye Institute Credentialing and Privileging Committee or the Credentialing Committee Chairman/Medical Director may implement a corrective action plan in order to allow a Member the opportunity to improve his/her quality of care or cure any breech of agreement between the Member and the University Eye Institute. The Member must comply with any corrective action plan within the time frames established or be subject to further disciplinary action. The University Eye Institute Credentialing and Privileging Committee monitors the Member for compliance with the corrective action plan. The University Eye Institute Credentialing and Privileging Committee may grant temporary appointment or temporary re-appointment to a practitioner who is under a corrective action plan.

Suspension/Termination

The Dean or the Credentialing and Privileging Committee Chairman/Medical Director / Executive Director, or any University Eye Institute Credentialing and Privileging Committee Member may initiate summary suspension whenever a Member’s conduct requires that immediate action be taken to prevent danger to life, or injury to him/her, patients, employees, or others. A summary suspension is effective immediately and requires that the Member cease clinical practice at the time of suspension. The University Eye Institute Credentialing and Privileging Committee Medical Director/ Executive Director/ Chairman is responsible for ensuring that prompt notice of the summary suspension is provided to the Member and to the Dean. The Department Chairman must assign all of a suspended Member’s patients to other University Eye Institute Members and, when feasible, consider the patient’s wishes in choosing substitute practitioners.

As soon as possible, the University Eye Institute Credentialing and Privileging Committee Medical Director/ Executive Director / Chairman will review and consider the suspension. He/She may recommend modification, continuation, termination or lifting of the suspension terms. Unless the University Eye Institute Credentials Committee Medical Director/ Executive Director /Chairman recommends the suspension be immediately lifted or modified to a lesser sanction, the Member is entitled to the procedural rights contained in the Appeals Process.

The University Eye Institute Credentialing and Privileging Committee, in consultation with the Credentialing and Privileging Committee Chairman/Medical Director/ Executive Director, may vote to terminate membership. A Member who has been terminated from the University Eye Institute for reasons of competence, quality or care, or professional conduct is entitled to appeal the decision in accordance with the University Eye Institute Appeals Process. A Member who has been terminated from the University Eye Institute for reasons of competence, quality of care, or professional conduct may not reapply to the University Eye Institute for a period of two (2) years unless specified otherwise in the terms of the disciplinary action.

Terminated appointments and suspensions lasting more than thirty (30) days must be reported to the NPDB and the TSBME or TOB in accordance with the regulations governing participation in these organizations. Any disciplinary action may be reported to a University Eye Institute payor(s) in accordance with contractual obligations.

Appeals Process

Any practitioner who has been denied re-appointment or whose Member status has been reduced, restricted, suspended, or terminated based on reasons of competence, quality of care, or professional conduct may appeal the action as follows:

Within thirty (30) calendar days of the Member’s receipt of notification of a disciplinary action, the Member must submit a written request for an appeal to the University Eye Institute Credentialing and Privileging Committee Medical Director/ Executive Director Chairman.

Within fourteen (14) calendar days of receipt of the Member’s request to appeal, the University Eye Institute Credentialing and Privileging Committee shall appoint a Review Panel of Department Members and establish a mutually convenient time, place, and date of a meeting between forty-five (45) and ninety (90) days from receipt of the Member’s request. At least one member of the Review Panel must practice the same or similar specialty or sub-specialty as the Member under review. The University Eye Institute Credentialing and Privileging Committee Medical Director / Executive Director / Chairman shall notify the Member of the meeting by certified mail.

Within fourteen (14) days after the meeting, the Review Panel shall render a recommendation to the University Eye Institute Credentialing and Privileging Committee with copy to the Member.

Within thirty (30) days of receipt of the Review Panel’s recommendation, the University Eye Institute Credentialing and Privileging Committee will review and forward its recommendation along with the Review Panel’s report to the Medical Director of the University Eye Institute.

At its next regularly scheduled meeting, the University Eye Institute Medical Director / Executive Director shall consider the recommendation of The University Eye Institute Credentialing and PrivilegingCommittee and render a decision. A Member will not be terminated prior to the end of the Appeals Process.

Within ten (10) days of the University Eye Institute Credentials Committee meeting, the University Eye Institute Credentialing and Privileging Committee Medical Director / Executive Director / Chairman, on behalf of the Dean, shall notify the Member of the decision. The decision of the Medical Director / Executive Director and Dean is final.

No Member shall be entitled to more than one appeal of any disciplinary action. Following termination of Member status, the practitioner shall not be permitted to reapply for membership for a period of two (2) years.

A Member’s failure to follow through or meet deadlines at any stage in the Appeals Process shall be considered a withdrawal of his/her request for an appeal.

XI. DELEGATED CREDENTIALING

Credentialing Delegated by Payors

In order to provide efficient service to its Members, University Eye Institute seeks the delegation of credentialing functions from its contracted payors where appropriate.

Prior to delegation, the University Eye Institute will work with its payors to assess the compatibility of the University Eye Institute Credentialing Program with each payor’s credentialing standards and expectations.

When delegation of credentialing functions is mutually acceptable, a delegation agreement or similar document must be fully executed prior to the delegation of any credentialing function. The document shall include, at minimum, the following items:

• The activities to be delegated to the University Eye Institute and those retained by the payor;

• The frequency of reporting required of University Eye Institute by the payor;

• The frequency and process by which the payor evaluates the University Eye Institute performance and compliance with the payor’s credentialing standards and expectations; and

• The remedies available to the payor if the University Eye Institute fails to comply with its contractual obligations.

The University Eye Institute recognizes that each payor retains the right to approve, deny, suspend, or terminate any University Eye Institute Member from its own network.

The University Eye Institute Credentials and Privileging Committee Medical Director/ Executive Director /Chairman and the University Eye Institute Clinic Office Manager shall ensure University Eye Institute cooperation with its delegating payors in the following ways:

• Provide documents and reports necessary to conduct oversight at the agreed-upon frequency and as needed.

• Cooperate with the payor’s efforts to implement quality improvement and other activities.

• Provide the payor, NCQA, and regulatory bodies with access to its credentialing files and committee minutes, when appropriate.

• Distribute communications from and information about the payor to University Eye Institute Members, when appropriate.

• Request quality data from its payors for consideration during re-appointment.

• Use best efforts to cooperate with payors to implement corrective action plans where the University Eye Institute Credentialing Program is found to be deficient.

Credentialing Delegated to Other Entities

The University Eye Institute may choose to delegate any credentialing function to a Credentialing Verification Organization (CVO) or other credentialing entity. Delegation of any function shall require approval by the University Eye Institute Credentialing and Privileging Committee or the Medical Director / Executive Director.

Prior to delegation, the University Eye Institute shall evaluate a potential delegate for compliance with applicable NCQA and University Eye Institute credentialing and related standards. Where a potential delegate is NCQA certified, the evaluation consists of meetings between representatives of the University Eye Institute and the potential delegate to assess the compatibility of programs and schedules. If the potential delegate is not NCQA certified, the evaluation takes place in the form of an audit of credentialing files and policy documents.

Where delegation of credentialing functions is mutually acceptable, a delegation agreement or similar document must be fully executed prior to the delegation of any credentialing function. The document shall include, at minimum, the following items:

• The activities to be delegated and those retained by the University Eye Institute;

• The frequency of reporting required of the delegate;

• The frequency and process by which the University Eye Institute evaluates the delegate’s performance and compliance with the University Eye Institute credentialing standards and expectations;

• The remedies available to the University Eye Institute if the delegate fails to comply with its contractual obligations.

The University Eye Institute retains the right to approve, deny, suspend, or terminate any practitioner from its own network.

Each delegate shall be required to cooperate with the University Eye Institute in the following ways:

• Provide documents and reports necessary to conduct oversight at the agreed-upon frequency and as needed.

• Cooperate with University Eye Institute efforts to implement quality improvement and other activities.

• Provide the University Eye Institute, its payors, NCQA and regulatory or quasi-regulatory bodies with access to its credentialing files and other documents, when appropriate.

• Distribute communications from and information about the University Eye Institute to participating practitioners, when appropriate.

• Include quality data from the University Eye Institute for consideration during re-appointment, when available.

• Seek approval from the University Eye Institute prior to sub-delegating any function.

• Use best efforts to cooperate with the University Eye Institute to implement corrective action plans where the delegate’s process is found to be deficient.

In order to conduct effective oversight of the delegate (and sub-delegate, if any), the University Eye Institute performs oversight evaluations at least annually. For those delegates who are NCQA certified, the evaluation may consist of a review of the reports submitted by the delegate for compliance with contractual obligations. For those delegates who are not NCQA certified, the evaluation consists of a systematic review of the delegate’s policy and related documents and an on-site visit to audit credentialing files.

Where a delegate is found to be deficient in its compliance with NCQA or University Eye Institute standards, the University Eye Institute shall work with the delegate to develop a corrective action plan. The University Eye Institute shall provide the delegate with a reasonable period of time to correct each deficiency. If a delegate remains deficient, the University Eye Institute has the right to terminate its relationship with the delegate.

All pre-delegation and annual evaluations are performed by the University Eye Institute Managed Care Director and are reviewed by the University Eye Institute Credentials Committee.

XII. ANNUAL EVALUATION AND WORKPLAN

The Credentialing and Privileging Committee, in consultation with legal counsel, shall review the Plan at least annually to ensure compliance with applicable law, NCQA standards, payor standards, and by-laws and policy. Revisions will be prepared and adopted by the Credentialing and Privileging Committee where appropriate.

The Credentialing and Privileging Committee will develop an annual workplan to ensure that all required credentialing and related Program activities are planned and performed. The workplan shall be adopted by the Credentialing and Privileging Committee and may be modified from time-to-time as appropriate.

XIII. PLAN ADOPTION

The Members of the University Eye Institute Credentialing and privileging Committee reviewed, in formal session on ____________________________, the University Eye Institute Credentialing Plan. The Committee voted to adopt revisions to this Plan as written.

EXHIBIT A

UNIVERSITY EYE INSTITUTE APPLICATION FOR APPOINTMENT

( University Eye Institute Application for Appointment attached)

EXHIBIT B

DELEGATED CREDENTIALING ENTITIES

Plan Specific Policy and Procedures

1. Confidentiality Protection and HIPAA Compliance

Provider credentialing applications, primary source verifications, results of any quality/utilization review requirements or audits, medical record review and any other materials collected in association with the process of credentialing are confidential and must not be read or discussed by any employee or committee member on or off the premises unless it pertains to specific job or requirements of credentialing staff or Credentialing Committee members responsibilities.

1. Confidential Maintenance of Credentials and Recredentialing Files:

1. All individuals participating on Credentials Committee or as employee of University Eye Institute Managed Care Department must sign a conflict of interest/confidentiality agreement.

2. File Maintenance and Storage: All credential files are kept locked in a location Room 1208 in the Clinic Business Office. Updates, including additions, deletions and reorganizations of the credentials files, as well as any other credentials file editing are recorded consistently, and such record also includes the dated signature and printed name of the individual making the change to the file. Credentialing files will be maintained for the lesser of seven (7) years or as required by applicable law.

3. Computer Security Measures: As necessary and applicable, access to computer logins will be limited to necessary personnel. Logins may be periodically changed to maximize computer security. Logins of staff whose participation in the credentialing activities terminates for whatever reason will be terminated promptly.

4. Transmission of Credentialing Information and Authorized Disclosures: The transmission of credentialing information between the credentialing committee, credentialing department employees, and any of its agents shall be made only while maintaining the strict confidentiality of the credentialing information. No such transmission is intended to be construed as a disclosure of confidential information or a waiver of the confidentiality privilege. [CR 1.9].

In addition, the following disclosures are authorized: A. To or between another peer review committee B. State or Federal agencies C. National accreditation bodies, including NCQA; or D. The state board of licensure of any state. Such authority to disclose expressly includes, but not limited to, the potential sharing of credentialing information between the credentialing committee and the authorized agents of such committees. Any transmission of peer review credentialing information shall include the notice on the transmitting document that the attached information is confidential and should be treated strictly as such .

5. File Destruction: Following termination of the file retention period set forth in Section 1.1.2, the credentialing files will be shredded and disposed of per applicable law.

2. Applicants or Provider Member Review of Credentialing and Recredentialing Information. A new applicant or existing provider member has the right, upon reasonable notice to the credentialing committee members or one of its designated agents, to review all information submitted by that individual or by third parties in support of his or her application or re-application for membership [C.R. 1.5].

3. Notification of Varying Information: If information obtained by the credentialing committee or its designee during credentials verification for application or reapplication is determined by the credentialing committee or its designee to vary substantially from the information provided in the application, the credentialing committee, or its designee, shall provide the applicant with written notification of varying information describing (a) the nature of the discrepancy and (2) the opportunity afforded to the applicant to review the file and submit supplemental and/or corrected information as set forth below in Section 1.4 [CR 1.6] [Survey Guidelines for CR 1.6, CR 1.7].

4. Opportunity to correct Erroneous Information.

The goal of the credentialing committee is to afford new applicants and existing members every opportunity to correct erroneous information so long as progress of the credentialing activities is not unduly impeded and the credentialing committee or Clinic’s compliance with requirements whether federal , state, or quasi regulatory standards are not jeopardized. An affected individual is notified of his or her right to correct erroneous information. The following general parameters are established, but may be waived if the credentialing committee determines the waiver of a parameter is in the best interests of the University Eye Institute.

1. Time frame for Corrections or Changes in Information.

A. Following Notification of Varying Information:

Following applicant’s or provider member’s receipt of a notification of varying information memorandum, an applicant or provider member will be afforded a ten (10) day opportunity to notify the credentialing committee or its designee that the individual believes the submitted information is erroneous. Corrected and/or supplemental information may be submitted up until seven (7) business days before the application is scheduled for review by the credentialing committee [Surveyor Guidelines for CR 1.6, CR 1.7].

B. Applicant’s independent discovery of discrepancy: If an applicant or existing member independently discovers a discrepancy in his or her credentials file, he or she must promptly notify the credentialing committee or its designee in writing of the alleged discrepancy. Corrected and/or supplemental information may be submitted up until seven (7) days before the application is scheduled for review by the Credentialing Committee. [Surveyor Guidelines for CR 1.6, CR 1.7]. C. Failure to Correct: If correct and/or supplemental information is not timely submitted, initial application may be denied as incomplete and reapplication mat be terminated as administratively inaccurate.

5. Format for Submitting Corrections:

Corrections must be submitted in writing and accompanied by any necessary and/or supporting documentation. [Surveyor Guidelines CR 1.6, CR 1.7].

6. Submissions of Corrections: Corrections should be submitted to the Credentialing Committee or one of its designees indicating that the information is in response to a notification of varying information.

2. Credentialing Criteria

2.1 General Criteria for all Applicants and Existing Members

2.1.1. The individual must be of sound moral character and must not have been convicted of or under investigation with respect to any crime involving dishonesty, fraud, deceit, or misrepresentation and/or any offense related to his or her professional practice or which in any respect would reasonably be viewed as reflecting adversely on University Eye Institute reputation should the individual become or remain a member of the University Eye Institute.

2. The individual must not presently be suspended or excluded from participating in a Federal Health Care Program(s) or under investigation resulting from participation in such Federal Health Care Program(s) and must fully inform Credentialing Committee about any prior suspensions, exclusions, or investigations either prior to or after becoming a member of the University Eye Institute.

3. The individual applicant must not presently be subject to any probation or suspension of hospital staff privileges or hospital registration, as applicable, State licensure, DEA number, or State Controlled Substance certificate, where applicable. Any probation, suspension or termination, whether current or in the past, for professional competence or quality of care issues shall be grounds for automatic denial or termination from continued participation in the University Eye Institute.

4. Advise Credential Committee or its assigned designee immediately upon the occurrence of any change or alteration in the information provided in the Practitioner’s initial application or reapplication.

2.2 Criteria for All Applicants.

A. A valid and unrestricted license to practice medicine or optometry in the State of Texas.

B. All appropriate approvals to prescribe and dispense drugs under applicable federal and State laws.

C. Board Certification or satisfactory completion of a residency program in Practitioner’s specialty and obtaining Board certification within the time-frame designated by such specialty board not to exceed five (5) years.

D. Professional liability coverage as follows [CR 4.5] (1) Continuous professional liability coverage in amounts of at least $200,000 per occurrence and $600,000 in the aggregate.

(2) Able to demonstrate evidence of tail coverage; and

(3) Notify Credentialing Committee of any change in such coverage

E. Completion of the Texas Common Credentialing Application and any addendums/attachments requested. The provider application shall include a statement by applicant regarding the following critera:

1) The provider will accept new patients;

2) Appropriate twenty-four hour coverage;

3) Lack of present illegal drug use;

4) History of loss of license and/or felony convictions;

5) History of loss or limitation of privileges or disciplinary activity;

6) Reasons for any inability to perform essential functions of the position, with or without accommodations;

7) An attestation to the correctness/completeness of the application signed and dated by the applicant within 180 days prior to the Credentialing Committee final approval.

8) The applicant will accept new patients.

F. Obtain and maintain medical staff privileges in good standing, when applicable.

G. Include a work history covering no less than 5 years.

H. The ability to apply and receive Medicare Provider number and Medicaid TPI number.

3.0 Procedure for the Initiation of Non-Adverse Corrective Action(s) or Adverse Action(s) to the Denial for Department Membership [CR 11].

3.0.1 Initiation of Process

Non Adverse Correction Action and Adverse Action may be initiated by submission of a written statement to the Credentialing Committee and Chairman/ Medical Director. Such action may arise when a Practitioner, and/or Allied Health Professional are considered to have exhibited activities or professional conduct lower than the standards of the Clinic or College in general.

3.0.2 Non Adverse Corrective Actions

A. Caution:

The Credentialing Committee may issue an oral or written “caution” to any Practitioner or Allied Health Professional within the University Eye Institute about an aspect of the Practitioner’s or Allied Health Professional’s conduct whenever the Credentialing Committee determines that the aspect of care or conduct should be brought to the attention of the Practitioner or Allied Health Professional. If the caution is in writing, a copy of the caution is furnished by the Credentials Committee to the Practitioner or Allied Health Professional. Unless otherwise directed by the Credentialing Committee, a caution does not become a part of the Practitioner’s or Allied Professionals credentialing file.

B. Special Review Requirements:

The Credentialing Committee may require an imposition of (1) a special program of consultation; (2) a special program of monitoring, education, or training; (3) a special program of retrospective, concurrent, or prospective review of the Practitioner’s or Allied Health Professional activities; or (4) any other special program designed to review or correct deficiencies in the quality of care by any one or more Practitioners or Allied Health Professionals whenever the Credentialing Committee has cause to believe that the deficiencies in the quality of care may exist and the special program order is appropriate mechanism to review or correct the deficiencies.

C. Letter of Warning or Reprimand:

A letter of warning or letter of reprimand may be issued to a Practitioner or Allied Health Professional by the Credentialing Committee, in the course of its quality monitoring of Members, determines that a Practitioner or Allied Health Professional has failed to provide appropriate care or has otherwise failed to comply with the Policies and Procedures of the University Eye Institute.

A letter of warning or of reprimand does become a part of the Practitioner’s or Allied Health Professional’s credentialing file. Removal of the letter of warning or reprimand is solely at the discretion of the Credentialing Committee.

3.0.3 Notice of Recommendation of an Adverse Action

When the Credentialing Committee that an Adverse Action is necessary, the Credentialing Committee will provide the affected Practitioner or Allied Health Professional with a written notice of an Adverse Recommendation and inform the Practitioner or Allied Health Professional of the opportunity to request a Reconsideration Review and potentially an Appeals Hearing.

4. Summary Suspensions:

Notwithstanding the notice provision above, a Practitioner or Allied Health Professional may be summarily suspended in instances where there is:

A imminent harm to the patient health ( as determined by the Credentialing Committee)

A an action by State or Federal licensing board or other government agency that impairs the Practitioner’s or Allied Health Professional’s ability to practice his or her profession

A fraud or malfeasance.

3.0.5 Due Process and Fair Hearing Procedure for Adverse Actions [CR 11.2].

Due Process and fair hearing procedures are available to a Practitioner or Allied Health Professional. Due Process procedures include a Reconsideration Review. In addition, they include a formal Appeals Hearing if the Practitioner or Allied Health Professional receives an Adverse Action to terminate his or her continued membership in The University Eye Institute based upon quality of care or other peer review based decisions.

4. Credentialing File

1. Applicant’s Credentialing File

A A Credentials File for each UEI provider and applicant shall be maintained in Room 1208 in the Clinic Business Office, which is designated as a security sensitive area requiring background check and key access requirement for entrance.

B. Upon request a provider or applicant shall have access in accordance to the policy 1.2 Applicants or Provider Member Review of Credentialing and Recredentialing Information.

C. Upon the completion of an executed application, a credentialing file shall be developed for ach provider under consideration.

D. Active files shall be maintained by the Credentialing Specialist in a locked file cabinet in Room 1208.

E. Inactive files shall be stored in a locked files in Room 1208, separate from active files.

F. The Credentialing Specialist shall serve as custodian of the provider’s credentialing file.

2. Content’s of Credentialing File

A. Texas Standardized Credentialing Application

B. Approval Form

C. Copies of Verifications of current state DPS, DEA certificate, NPDB, and Medicare/Medicaid activity/applications.

D. Evidence of current Malpractice Insurance Coverage

E. Malpractice claims history, if applicable.

F. Board Certification, if applicable.

G. Continuing Medical Education.

H. Verifying Documentation, such as Hospital Privilege Letter or Personnel References

I. Correspondence.

J. Academic CV/ Work History (no less than 5 years).

K. Copies of degrees/certifications

3. Supplemental criteria that shall be reviewed at time of recredentialing by the Credentialing Committee:

A. Patient Complaints/Complements

B. Results of Quality Improvement Activities

C. Utilization Management

D. Parent Satisfaction Surveys

E. Office Site Visit review(s)

F. Medical record Review

4. Primary Source Verification

A. A current valid, and unrestricted license free of state sanctions, probation, or limitations from either the Texas Optometry Board or the Texas State Board of Medical Examiners and all other out-of-state licensing agencies. A copy of the current (date stamped) original license shall be maintained in the provider’s credentialing file. Primary source verification not to exceed 180 days.

B. Primary Source verification shall be obtained via telephone, on-line verification, or in writing from the State Board of Medical examiners or Texas Optometry Board.

C. Obtaining report(s) from National Practitioner Data Bank (NPDB) shall be verified within 180 days prior to the date of the initial credentialing ad recredentialing decision.

D. Initial and Recredentialing Verification of Out-of-State Medical License – Primary source verification shall be obtained from each state in provider maintains or has maintained a license to practice as indicated on initial credentialing application.

E. Reporting of Adverse Actions shall be transmitted in writing to any payors in which University Eye Institute has a delegated credentialing agreement with of any adverse actions that UEI is made aware of during the course of verifying, maintaining or during any recredentialing process.

5. Professional Work History

A. Each applicant/provider shall provide a minimum of five (5) year professional work history at initial credentialing and recredentialing:

B. Information shall be provided on the Texas Standardized Credentialing Application in the work history.

C. A curriculum vitae.

D. No unexplained gaps in professional work history greater than 6 months is acceptable.

6. Malpractice Liability Insurance

A. A minimum limit of $200,000 - $600,000 of professional malpractice liability insurance required

B. A current, valid, date stamped copy of the certificate of malpractice coverage indication amounts of coverage and dates of coverage shall be placed on providers file

C. The primary source shall not exceed 180 days

D. The malpractice coverage may also be verified in writing by contacting the malpractice carrier directly

7. Reporting Adverse Actions

Participating health plans the University Eye Institute has delegated credentialing agreement to be notified within five business days of any adverse actions from the Texas Optometry Board or from Texas State Board of Medical Examiners; Office of Personnel Management; Office of Inspector General; and Texas Health and Human Services. In the event of an Adverse Termination, provider will be terminated from all contracted health plans, and due process for removal from University Eye Institute will be followed. All correspondence to payors in an effort to resolve any adverse findings shall be completed by the fifth business day.

A. Medicare and Medicaid – UEI will review Medicare and Medicaid status on a monthly basis from the Office of Inspector General’s List of Excluded Individuals/Entities. Reports are reviewed within thirty days of their release. The UEI Credentialing Specialist will notify the Credentialing Committee of any adverse information obtained for review.

B. Sanctions and/or Limitations on Licensure – The appropriate State Licensing Board shall be queried on a monthly basis and at the time of initial credentialing and recredentialing. When a licensing sanction is identified, the practitioner is forwarded to the Credentialing Committee for review, discussion and action.

C. Complaints – UEI will monitor and act on both verbal and written complaints received by health plan as well as those received through other available avenues on a monthly basis. Complaints shall be investigated in a timely and thorough manner and reported to the Credentialing Committee Chairman/Medical Director for review. The Credentialing Specialist shall document and review complaint activity received, and establish if any trends or patterns are emerging for immediate intervention from Medical Director/Chairman.

D. Quality of Care Concerns – When a quality of care concern or identified adverse event is identified, the practitioner is forwarded to the Credentialing Committee for review. History of adverse events shall be tracked, monitored, and reviewed every six months to evaluate trends and issues.

8. Professional References

A. Each applicant/provider shall supply a least three (3) professional references, not including partners or relatives, of the same specialty who have direct knowledge of clinical abilities and health status at initial credentialing

B. Credentialing Specialist shall notify applicant in writing of any failure of others to respond to request for information

C. After such notice, the applicant shall have the obligation of securing these written responses.

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