Participation criteria for sleep medicine practitioners

Behavioral health practitioners credentialed in Sleep Medicine will be allowed to bill for services related to a medical or sleep disorder diagnosis.  In order to be allowed acceptance into or continued participation in Priority Health, practitioners must satisfy the following listed criteria.

1. Doctoral degree (Ph.D., Psy.D., Ed.D.) in clinical counseling or psychology from an Accredited College or University;
2. Current certification as a Diplomat of the American Board of Sleep Medicine;
3. A valid, current, and unrestricted license or certification to practice as a psychologist in the State of Michigan.  Practitioners must provide information regarding any previous loss of license or any voluntary relinquishment of license and provide evidence that these earlier incidents do not demonstrate probable future substandard professional performance;
4. Practitioner must be in good standing under the Medicare and Medicaid programs;
5. Practitioner must maintain current professional liability insurance coverage meeting minimum limits of $1,000,000 per occurrence and $3,000,000 aggregate which must cover use of therapeutics and covers each practitioner individually (should a practitioner not meet the coverage limit requirements, Priority Health will consider exceptions based on need of practitioner type or geographic needs);
6. Practitioner must have an absence of a history of involvement in a malpractice suit, arbitration or settlement; or in the case of a practitioner with this history, evidence must be provided that the history of malpractice involvement is not indicative of probable future substandard professional performance;
7. Practitioner must have an absence of a history of denial or cancellation of professional liability insurance; or in the case of a practitioner with this history, evidence must be provided that the history is not indicative of probable future substandard professional performance;
8. Practitioner must meet contractual requirements for after hours coverage for specialty care practitioners;
9. Practitioner must have an absence of a history of involuntary termination of employment or contract as a health care practitioner; or in the case of a practitioner with this history, evidence must be provided that this history is not indicative of probable future substandard professional performance;
10. Practitioner must have an absence of a history of professional disciplinary action; or in the case of a practitioner with this history, evidence must be provided that this history is not indicative of probable future substandard professional performance;
11. Practitioner 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.  Practitioner must avoid conduct which reflects adversely on their professional fitness;
12. Practitioner must have an absence of a history indicating (in the sole discretion of Priority Health) a tendency toward inappropriate utilization management of medical resources;
13. Practitioner must have an absence of a history of criminal conviction or indictment; or in the case of a practitioner 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;
14. Practitioner 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;
15. Practitioner 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, practitioner must cooperate openly and fully with any required health assessment and must provide any reasonably requested evidence of health status.
16. Practitioner must comply with all Priority Health rules, regulations, bylaws, and the terms of their practitioner participation agreements.
17. Practitioner must demonstrate their willingness to provide appropriate and necessary emergency or nonemergency medical treatment within the scope of their expertise to any Priority Health member seeking treatment.
18. Practitioner 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.
19. Practitioner shall not have falsified information on their applications or failed to notify the Physician Credentialing Committee regarding relevant changes in their status.