Credentialing

Appeals and Terminations

HMO Louisiana, Inc., a subsidiary of Blue Cross and Blue Shield of Louisiana (BCBSLA), has adopted all BCBSLA credentialing policies and procedures. All information specific to provider denials, terminations, appeals and hearings is considered highly confidential. This policy applies to all health care providers.

The Network Administration Vice President, Medical Director, Credentialing Subcommittee or Medical and Quality Management Committee (MQMC) may act to deny or terminate a provider's participation in the Blue Cross and Blue Shield of Louisiana and HMO Louisiana, Inc.'s (The Organizations') network(s).

Providers may appeal decisions of the organization to terminate participation based on quality of care or service issues or unacceptable resource utilization. The request must be received within 30 days of the notice of the proposed action. In addition, the appeal process is not available to providers with terminations based on the 'without cause' provisions of the provider network agreement(s).

Providers are notified of their appeal and hearing rights in their termination letter. A copy of the appeal and hearing procedures is mailed with the termination letter. A provider who fails to observe the terms and conditions of the Organizations' Network Provider Agreement, including, but not limited to, the credentialing or recredentialing standards, may be terminated from the network(s). In cases where the Medical Director determines that circumstances may pose an immediate risk to any member, a provider may be summarily suspended from the network(s) for further investigation.

If a provider voluntarily terminates from the network(s) and requests to become reinstated again within six months from the termination date, s/he will not be required to be credentialed again if their credentialing status is reinstatable, as it has not expired in the meantime. The physician must explain the lapse of participation in writing and the explanation will be included in the provider's file. The provider's original credentialing date will be reinstated and the provider will be recredentialed according to the Organization's policies. The provider must sign a new agreement for each network in which s/he is requesting to participate.

All external physician members of the appeals committees are network peers not in direct economic competition with the provider involved and who have not participated in initiating or investigating the underlying matter at issue or who had no responsibility for making the proposal giving rise to the hearing.

The Network Operations Department provides written notification to appropriate authorities, including the National Practitioner Data Bank (NPDB) and the appropriate state board on all terminations related to reportable actions. The notification will be sent via letter within 30 days of the effective date of the termination.