Practitioner credentialing

Credentialing is the important and necessary process of obtaining, verifying, and assessing the qualifications of a health care practitioner to provide patient care services in or for a health care organization.

Your rights

You have the right to review information submitted in support of your credentialing application and to correct erroneous information. You may not review peer reviews, peer references, and other peer-review protected materials.

You also have the right, upon request, to be informed of the status of your credentialing or recredentialing application.

Initial credentialing and recredentialing

You must be credentialed before providing covered services to our members.

To initiate the initial credentialing process, you must fill out the proper forms to join the network, or to add someone to your group.

View requirements, forms and apply to join.

Provider Services will review and forward your information to the Credentialing department.

Applications for initial credentialing and recredentialing are only accepted through the approved universal credentialing data sources. Please submit your Washington Practitioner Application form (WPA) through CAQH. You must select "Kaiser Foundation Health Plan, Washington Region" to allow us to view/pull your application. Paper applications are not accepted.

You must complete our credentialing process and be approved by our Credentialing Committee. We will notify you in writing when your application is approved. The contracting process begins once credentialing approval is completed.

You must be recredentialed at least every three years.

Credentialing health care delivery organizations

As a managed care organization, Kaiser Permanente credentials the following health care delivery organizations (HDOs):

• Hospitals
• Free-standing surgical centers, including birth and endoscopy centers
• Mental health agencies providing mental health or substance use services in an inpatient, residential, or ambulatory setting
• Home-health agencies
• Skilled nursing facilities
• Hospice
• Clinical laboratories
• Comprehensive Outpatient Rehabilitation Agency/facility
• Providers of end-stage renal disease services
• Providers of outpatient diabetes self-management training
• Portable X-ray suppliers
• Rural health clinics (RHCs)
• Federally qualified health centers (FQHCs)
• Imaging centers

The assessment process includes primary source verification to ensure that HDO providers are licensed and in good standing with regulatory bodies. All facilities must submit proof of malpractice insurance and claims history.

The assessment also verifies that providers are accredited by an appropriate accrediting agency before contracting and every three years thereafter. We have also developed standards of participation for unaccredited HDO providers and will assess them accordingly.

Dispute resolution process (nonreportable events) & appeals process (reportable events)

Dispute resolution is available to eligible practitioners who have been denied initial credentialing or recredentialing for administrative reasons, such as failure to meet credentialing criteria, privileging criteria, or both. The appeal process is for eligible practitioners who have been denied initial credentialing, recredentialing, or privileging by Kaiser Permanente's Credentialing Committee, Board of Directors, or an authorized committee of the board. It also is the appeals process for practitioners who are the subject of an official action or recommendation for the reduction, restriction, suspension, revocation, termination, denial, or failure to renew membership, privileges, or both. This denial decision is reportable to the National Practitioner Data Bank (NPDB), and the appropriate state licensing board in accordance with applicable law and Kaiser Permanente policy.

Brief summary of dispute process

Following an action by our Credentialing Committee to deny the application for initial credentialing, recredentialing, or privileges, the credentialing director or designee will send a notice of action to the affected practitioner.

To initiate the dispute resolution process, the affected practitioner must submit a written request for review to the credentialing director or designee no later than 30 days following receipt of the notice of action. The practitioner may submit additional information for consideration or request a personal meeting. The practitioner may have an authorized representative attend the meeting with him or her or on their behalf.

If additional information is submitted, we will notify the practitioner of our determination within 21 days of receipt of the information. If a meeting is requested, we will respond within 14 days after the conclusion of the dispute meeting.

If the practitioner has exhausted the dispute resolution process and is not satisfied with our determination, he or she may request mediation by submitting a written request to the credentialing director or designee no later than 14 days following receipt of our determination. The request for mediation shall constitute the practitioner's promise to pay one half of an approved mediator's charges.

Brief summary of appeals process

Following an adverse action or a recommendation for adverse action, the Credentialing Committee chair or designee will provide written notice to the affected practitioner. In order to appeal, the practitioner must send within 30 days of receiving notice a written request for a hearing and a statement explaining the basis for contesting the adverse action.

The hearing is conducted in the presence of the hearing officer, the Hearing Committee, and the practitioner. A record of the proceedings shall be maintained which, together with documentation and exhibits submitted by the parties, shall constitute the hearing record.

Within 20 days after closure of the hearing, the Hearing Committee will make a written report and recommendation and will forward those items together with the hearing record to the chair of the Credentialing Committee and to the appealing practitioner.

The Credentialing Committee will take action within 30 days after receiving the final report of the Hearing Committee. Notice of its action will be sent to the practitioner within 10 days.

If required by law, the credentialing director or designee will report the final action to the appropriate state licensing board and the NPDB. Kaiser Permanente also will send a copy of the final report to the practitioner.

Contact information

For more information or a formal description of the entire processes, send your written request to:

Director, Medical Staff Office
Kaiser Foundation Health Plan of Washington
Provider Credentialing, RCR-A2N-20
PO Box 9010
Seattle, WA 98057-9010