Participation criteria for behavioral health physicians

In order to be allowed acceptance into or continued participation in Priority Health, physicians must satisfy the following listed criteria.

1. Physicians applying for participation after September 1998 are required to be Board Certified or must have graduated from an approved program and have completed a minimum of three (3) years of post-graduate professional education in the area of practice in which the practitioner will serve Priority Health patients (exception to these criteria are listed below).  For these physicians, Board certification in their area of practice will be required.  Participating practitioners who were not Board Certified as of September 1998 were grandfathered.  Recent graduates of residency programs who are not board certified at the time of application must attain board certification within five years of completion of the training program.  Priority Health will recognize board certification from the following agencies:
• The American Board of Medical Specialties (ABMS)
• The American Osteopathic Association (AOA)
• The American Board of Podiatric Surgery; or The American Board of Podiatric Orthopedics and Primary Podiatric Medicine
• The American Board of Oral Surgery

If a physician is not Board Certified or Board Eligible as a recent graduate of a residency program, he/she must:
• Have completed post graduate clinical training prior to 1989 and
• Practice in a rural area (defined as a non-urbanized area by the U.S. Bureau of the Census)1; or
• Practice in an area designated by the Department of Health and Human Services as a Medically Underserved Area (MUA) or a Health Professional Shortage Area (HPSA); or
• Practice in a Group Practice with current Priority Health participating practitioners
• Practice in a geographic location designated by Priority Health as an area with insufficient provider coverage
• Practice a medical specialty identified by Priority Health as having a shortage of providers to meet membership demand.

If one of the above exception criteria applies, the applicant practitioner must meet the following requirements:
• If a PCP, satisfactorily complete a site visit and medical record keeping review, and
• Submit two previous years of documentation of CME credits completed annually, directly related to practitioner's stated specialty, and
• Three satisfactory letters of recommendation from physicians who are familiar with clinical skills and who are not employed with or partners of the physician group the applicant is joining.
• Practitioner must continue to meet the exception criteria in addition to the remainder of the Acceptance/Continued Participation Criteria.
2. Physicians must hold valid, current, and unrestricted licenses/required certifications issued by the State(s) in which they practice their healing art.  Physicians must provide information regarding any previous loss of license or certification, or any voluntary relinquishment of license or certification, and provide evidence that these earlier incidents do not demonstrate probable future substandard professional performance.
3. Physicians must hold a valid, current Drug Enforcement Agency registration or provide evidence that they do not require such registration to deliver appropriate care.
4. Physicians must hold current clinical privileges in good standing (this includes all membership and privilege status categories of Active, Courtesy, Provisional, Temporary, etc.) at a licensed hospital or provide evidence that they do not require hospital clinical privileges to deliver satisfactory professional services.  Evidence that Priority Health is aware that the physician is without clinical privileges and that the physician has made arrangements for in-house coverage of his or her Priority Health patients by physicians with privileges shall suffice to fulfill this requirement.
5. Physicians must provide information regarding any previous loss of privileges or voluntary relinquishment of privileges at a licensed hospital, and provide evidence that these earlier incidents do not demonstrate probable future substandard professional performance.
6. Physicians must be in good standing under the Medicare and Medicaid programs.
7. Physicians must maintain current professional liability insurance coverage meeting minimum limits of $100,000 per occurrence and $300,000 aggregate for one (1) year.
8. Physicians must have an absence of a history of involvement in a malpractice suit, arbitration, or settlement; or, in the case of physicians with this history; evidence must be provided that the history of malpractice involvement is not indicative of probable future substandard professional performance.
9. Physicians must have an absence of a history of denial or cancellation of professional liability insurance; or, in the case of physicians with this history, evidence must be provided that the history is not indicative of probable future substandard professional performance.
10. Physicians must have an absence of a history of involuntary termination of employment or contract as a health care practitioner; or, in the case of physicians with this history, evidence must be provided that this history is not indicative of probable future substandard professional performance.
11. Physicians must have an absence of a history of professional disciplinary action; or, in the case of physicians with this history; evidence must be provided that this history is not indicative of probable future substandard professional performance.
12. Physicians must have an absence of a history of failing to conduct themselves with a professional demeanor or of engaging in abusive or destructive behavior in professional matters.  Physicians must avoid conduct which reflects adversely on their professional fitness.
13. Physicians must have an absence of a history indicating (in the sole discretion of Priority Health) a tendency toward inappropriate utilization management of medical resources.
14. Physicians must have an absence of a history of criminal conviction or indictment; or, in the case of physicians with this history; evidence must be provided that this history is not indicative of probable future substandard professional performance.  A conviction within the meaning of this criterion includes a plea or verdict of guilty or a conviction following a plea of no contest.
15. Physicians must have an absence of any history, in addition to that specified in other Criteria, that in any way is indicative of probable future substandard professional performance.
16. Physicians must have an absence, or adequate control of, physical, mental health, or substance abuse problems which may interfere with their ability to practice their profession or facilitate cooperative working relationships, or which may pose a threat to their patients.  In conjunction with this requirement, physicians must cooperate openly and fully with any required health assessment and must provide any reasonably requested evidence of health status.
17. Physicians must comply with all Priority Health rules, regulations, bylaws, and the terms of their practitioner participation agreements.
18. Physicians must demonstrate their willingness to provide appropriate and necessary emergency or non-emergency medical treatment within the scope of their expertise to any Priority Health member seeking treatment.
19. Physicians shall not be known to have made any misrepresentations to Priority Health's Board of Directors, employees, agents, or enrollees regarding the provision of services to enrollees.
20. Physicians shall not have falsified information on their applications or failed to notify the Physician Credentialing Committee regarding relevant changes in their status.