PROVIDER NETWORK REQUIREMENTS

Hospitals and Skilled Nursing Facilities/Institutes for Mental Disease (IMDs)

Hospitals and Skilled Nursing Facilities/IMDs must be licensed by the State Department of Health Services and meet national accreditation standards for staff qualifications. In order to participate in the SFMHP provider network, you must meet the state requirements listed in Appendix 11.

Organizational Providers

Organizational providers are certified by SFMHP and the State to deliver mental health services through Short-Doyle MediCal clinics staffed by licensed mental health professionals and interns under licensed supervision. Organizational providers who contract with the SFMHP must be certified for participation in the Medi-Cal program by the SFMHP. The SFMHP Quality Management Office facilitates and provides technical assistance in the process for MediCal program certification and re-certification for SFMHP operated organizational providers and conducts the actual review and certification for contract organizational providers. If your program is new, moving, or otherwise changing significantly, re-certification may be required. More information about this can be obtained by contacting the Program Certification Office in Quality Management at (415) 255-3661.

Organizational providers are expected to follow the SFMHP policy regarding professional licenses, certificates, registration and waivers (Policy 2.06-10). Copies of this policy are available from the Provider Systems Office at (415) 255-3773.

Individual and Group Practitioner Providers

Psychiatrists, licensed psychologists, licensed clinical social workers, licensed marriage and family counselors, and masters prepared nurses licensed for independent practice are eligible to participate as both individual and group practice network providers. Individual and group network providers must have valid California clinical licenses.

The credentials of practitioner providers must be verified before they can become members of the SFMHP Provider Network, whether they contract directly with the SFMHP or are part of an Individual Practice Association (IPA) or Individual Practice Organization (IPO). Their credentials may also be reviewed against standards set by the SFMHP and the needs of its beneficiaries before they are accepted as part of the Provider Network.

Initial Program Requirements for Practitioner Providers

A practitioner must have a contract on file in the Provider Systems Office in order to receive reimbursement for services provided to their continuing Fee-for- Service MediCal clients, or to receive referrals of new clients from the SFMHP. Contracts are awarded after credentials are verified and have been reviewed and approved by the Practitioner Review Committee. This process may take up to 45 days.

Credentialing of Practitioner Providers

The San Francisco Mental Health Plan (SFMHP) is responsible for selecting practitioners and defining policies and procedures that define the qualifications necessary to participate in its Provider Network. Membership as a Practitioner Provider in the Provider Network will be granted based on the results of a credentials verification process, and a review of the practitioner's credentials against the SFMHP quality standards and the needs of its beneficiaries. You will receive a response to your application within 45 days of submitting a complete application to the Provider Systems Office.

Maintaining Your Status As a Practitioner Provider in the Network

It is your responsibility as a SFMHP practitioner to inform the Provider Systems Office whenever there is a change in your qualifications.

The Practitioner Review Committee (PRC) will review your credentials whenever your license expires in order to assure that you continue to meet the standards for membership in the Provider Network; and whenever they receive a report that brings your credentials into question.

Before your license expires, the Provider Systems Office will contact you regarding your credentials review. This process will require that you update the credentials information you have on file with the Provider Systems Office.

Criteria used for credentials review are designed to assess a practitioner's ability to deliver care that meets the SFMHP standards. At the time of this credentials review, data derived from practice experience within the SFMHP may be used as part of the process of determining whether you will retain your membership in the Provider Network. This data may also include, but is not limited to, quality improvement findings, utilization review data, and client satisfaction survey results.

Loss of Status as a Practitioner Provider

Payment for services by practitioners may be suspended by SFMHP if there is no evidence on file with the Provider Systems Office that the practitioner has a current license or current malpractice insurance.

In addition, Practitioners may lose SFMHP provider status if the Practitioner Review Committee (PRC) finds that their credentials are compromised in a way that indicates they may not be qualified to provide services that meet the SFMHP's standards.

A practitioner's status may not be renewed if needs of SFMHP members have changed, or the standards of the organization have changed and the practitioner is no longer able to meet these standards.