Credentialing / Re-credentialing Information
Find out more about our credentialing process.
Credentialing / Recruitment Criteria
All Practitioners must complete the CareFirst CHPDC credentialing process prior to their inclusion in the network. Applicants of CareFirst CHPDC who are not actively enrolled with DC Medicaid and are required to enroll must ensure enrollment occurs. Please see information link below from the Department of Health Care Finance Transmitta#17-28 Appendix A which lists the provider and organizational types that must enroll.
You can access the PDMS website at: https://www.dcpdms.com/Account/Login.aspx.
If there are any questions, please contact the Department of Health Care Finance (DHCF) directly at (202) 698-2000.
To begin the credentialing processes please fill out the form by clicking on the button below
Council for Affordable Quality Healthcare Process (CAQH)
CareFirst CHPDC has identified an efficient process for credentialing/ re-credentialing practitioners through CAQH. CAQH stands for Council for Affordable Quality Healthcare. It is a not-for-profit organization that is a catalyst for industry collaboration on initiatives that simplify healthcare administration.
A Practitioner is eligible to be credentialed if they:
- Hold a current un-restricted license to practice in their profession in the District of Columbia
- Hold a current Federal Drug Enforcement Agency (DEA) Certificate or Controlled Dangerous Substance (CDS) certificate, if applicable
- Hold the current malpractice insurance limits for their specific discipline as required by CareFirst CHPDC
- Agree to provide information on sanctions and/or disciplinary action imposed by any other health institution, professional health care organization, licensing authority and/or regulatory body, including voluntary or involuntary limitation, reduction, or loss of clinical and/or technical skills, and current competence.
- Demonstrate a degree of professional competence comparable to other network Practitioners in their specialty, as well as the ability to deliver cost effective health care and meet the geographic, specialty and business needs of CareFirst CHPDC
- Agree to participate in all quality management activities required by CareFirst CHPDC Quality Management Department
- Provide professional work history to include the beginning and ending month for each position listed. A gap in work history that exceeds 6 months must be clarified in writing.
- Provide information, which pertains to all education, training, and board certification information
The credentialing process begins when the Practitioner submits a completed, signed and dated credentialing application and Consent and Release Form accompanied by copies of their state license, DEA or CDS, malpractice face sheet, and curriculum vitae. The Credentialing staff will then complete Primary Source Verification (PSV). In addition, site reviews will be conducted for all Practitioners utilizing the Office Site Review Tool, available upon request. The application, PSV and site review results are forwarded to the Credentialing Committee for a decision. The Credentialing Committee consists of participating network Practitioners. All Practitioners are sent written notification of initial credentialing/re-credentialing decisions.
All Practitioners must be re-credentialed within three years of their last credentialing date. CareFirst CHPDC re-verifies the information that is subject to change over time. Static historical elements such as education are not re-verified. The intent of the re-credentialing process is to identify any changes in the practitioner’s licensure, sanctions, certification, clinical privileges, competence, or health status that may affect the Practitioner’s ability to perform the services that they are under contract to provide. CareFirst CHPDC collects and conducts primary source verification on all re-credentialing information and documentation. In addition, the re-credentialing process incorporates an assessment of the practitioner’s performance with CareFirst CHPDC, which includes medical record review, access and site reviews, enrollee complaints, enrollee satisfaction, and information from quality improvement and Medical Management activities.
CAQH promotes quality interactions between health plans and providers. When a practitioner completes the on-line application with CAQH that practitioner has the ability to utilize one application for many different health plans. This reduces time, cost and frustrations associated with healthcare administration. It takes approximately 1.5 hours to complete one application. When filling out paper applications for several different health plans it may take several hours.