Can I see why the credentialing committee denied me?

Usually yes. Plan policies commonly let you review the information gathered on your application after a written, signed request, excluding references and peer-review protected material. Medicare Advantage and Medicaid managed care plans must also state their reason in writing.

How long do I have to ask for reconsideration?

It depends on the plan. One published Louisiana Medicaid plan policy gives 30 calendar days from receipt of the denial letter. Check your letter and the provider manual immediately, because windows are short.

Do I get a hearing if a Medicare Advantage plan denies my application?

Not necessarily. The peer hearing in 42 CFR 422.202(d) covers suspensions and terminations. For adverse participation decisions, coordinated care plans must provide written notice and an appeal process that lets physicians present information and views.

What happens if reconsideration fails?

Many plans bar reapplying for a period after a final denial. One published policy uses one year from the denial or the end of reconsideration.

Credentialing Committee Adverse Decisions: What You Can See and Correct

A credentialing denial is different from a closed panel. The plan was willing to consider you, reviewed your file against its criteria, and found a problem. Because the decision rests on facts about you, it can often be corrected, and plan policies usually give you specific rights to do that. The trouble is that those rights are time-limited and buried in provider manuals. Here is what they typically include and how to use them.

Who actually made the decision?

Most plans send files that meet every criterion (a "clean file") to a medical director for sign-off and send the rest to a credentialing committee of physicians and other clinicians. Medicare Advantage plans must run a documented credentialing process that includes "verification of licensure or certification from primary sources, disciplinary status, eligibility for payment under Medicare, and site visits as appropriate" (42 CFR 422.204(b)(2)(i)). Medicaid plans follow the state's uniform credentialing policy (42 CFR 438.214(b)).

A committee denial usually traces to one of a short list of items. One Louisiana Medicaid plan's published policy lists what keeps a file out of the clean track, including license or DEA limitations within five years, sanctions, malpractice settlements or plaintiff verdicts within five years, a work-history gap of one year or more in the last five, hospital privilege restrictions, a felony conviction (including a no-contest plea), and "involuntary terminations from an HMO or PPO."

What rights do applicants usually have?

Plans accredited by NCQA build applicant rights into their policies. The same Louisiana policy (Louisiana Healthcare Connections, LA.CRED.01) is a clear example:

Review. Practitioners may review information obtained to evaluate their application "upon receipt of a written and signed request." The plan sends it "within fourteen (14) days" of the request.
What is withheld. The review right does "not include the right to review references, personal recommendations, or other information that is peer review protected."
Correction. If information from primary-source verification differs from what you submitted, you have "the right to correct any erroneous information submitted by another party."
Status. You may get the status of your application "at any time."
Reconsideration. New practitioners denied "for non-administrative reasons" may request reconsideration "within thirty (30) calendar days of the date of receipt of the denial letter."

Other plans set different day counts. Read the denial letter and the plan's provider manual the day the letter arrives, and write down the date you received it.

Does Medicare Advantage require more of plans?

For coordinated care plans, 42 CFR 422.202(a) requires "reasonable procedures" for physician participation, including "written notice of participation decisions that are adverse to physicians" and "a process for appealing adverse participation procedures, including the right of physicians to present information and their views on the decision." The formal hearing with a majority-peer panel in 422.202(d) applies to suspensions and terminations of existing contracts, not to first-time applicants. Every plan that declines to include a provider must also give written notice of the reason (422.205(a)). The details are in Medicare Advantage adverse participation decisions and appeals.

How does reconsideration usually work?

Under the Louisiana policy, a timely request that includes "additional consideration for network participation" goes to "the Credentialing Committee at the next regularly scheduled meeting but in no case later than sixty (60) calendar days from the receipt of additional information." The committee either upholds the denial or approves the applicant, and the applicant is notified in writing within 60 days of the decision. If the denial stands, practitioners "may reapply for admission into the network no earlier than one (1) year following the initial denial or end of the reconsideration process."

That one-year bar is common, and it is why a careful reconsideration beats a quick reapplication. See reapplying after a network denial for timing.

What should you request before you respond?

The written reason, if the letter is vague. Medicare Advantage (422.205(a)) and Medicaid managed care (438.12(a)(1)) plans must give one. Our post on your right to a written reason has a model request.
The file under your review right: primary-source verifications, the NPDB report the plan received, and any site-visit score.
The criteria the committee applied, from the provider manual or credentialing plan.
The reconsideration procedure and its deadline, in writing.

Which errors are most often fixable?

A work-history gap that was actually leave, training, or a non-clinical role. Plans usually want gaps over six months explained and gaps over a year documented. Our sister service covers gaps in work history on credentialing applications.
A "yes" answer with no explanation, such as a board inquiry that closed with no action.
A malpractice entry that ended in a defense verdict or was paid by a carrier without your consent; see malpractice history and network credentialing.
Coverage below the plan minimum, cured by a new face sheet.
A privilege "restriction" that was a routine proctoring period for new staff.

Is there an exception process?

Often. The Louisiana policy lets the committee use "an exception process should it be necessary to credential certain practitioners given the needs of its membership," when circumstances keep you from meeting minimum criteria "but do not preclude the practitioner from providing quality care and service." If the plan is short of your specialty where you practice, say so in the reconsideration with evidence, not just assertion.

Does a denial get reported anywhere?

Sometimes. The same Louisiana plan notifies the state Medicaid agency when it denies a credentialing application "for program integrity-related reasons." Ask what, if anything, was reported, because a report can follow you to other plans and to state enrollment.

Who prepares what, and who signs?

We are not a law firm and we do not represent providers before plans or committees. In a Network Rejection Review ($249), we read the denial, request your file and the criteria (you sign the requests), and identify which items are errors and which need explanation. In a Payer Network Dispute ($799 per payer), we prepare the reconsideration letter and evidence package. You review, sign and send it, and we track the committee date. If the denial involves a privilege action or anything that could become a hearing, bring in a healthcare attorney. See our pricing page and the closed panels hub.