Credentialing

AmericasHealth Plan contracts with the best providers, medical institutions and allied health professionals to ensure that our members receive excellent healthcare and services.

The Credentials committee is responsible for credentialing and re-credentialing all healthcare providers to verify their professional qualifications. All credentialing and re-credentialing are performed in accordance with National Committee for Quality Assurance (NCQA) standards and guidelines. Credentialing documents are obtained through the Council for Affordable Quality Healthcare (CAQH). Providers who do not have a CAQH file may be required to complete a Practitioner Credentialing application. Gemini Diversified Services, a credentialing verification organization, conducts primary source verification, data collection and reporting services.

All providers must be qualified in accordance with current applicable legal, professional and technical standards and appropriately licensed, certified or registered. All providers must have good standing in the Medicare and Medicaid/Medi-Cal programs. Providers that have been terminated from either Medicare or Medicaid/Medi-Cal cannot participate in AmericasHealth Plan.

The Credentials Committee makes the decision to accept, retain, deny or terminate a practitioner’s participation in AmericasHealth Plan. The credentials committee does not make credentialing or re-credentialing decisions based on an applicant’s age, gender, race, ethnic/national identity, sexual orientation or types of procedures performed by the applicant.

AmericasHealth Plan may delegate specific credentialing and re-credentialing responsibilities to qualified entities. Before delegation is granted, the entity must submit written policies and procedures related to credentialing activities of potential plan network providers. The written policies and procedures must meet plan requirements for credentialing and re-credentialing.

AmericasHealth Plan’s designated staff, chief medical officer and the credentials committee have a responsibility to perform oversight of any delegated entity's credentialing and re-credentialing activities to ensure full compliance with AmericasHealth Plan policies and to make recommendations for improvement as appropriate. If the delegated entity fails to fulfill its obligations, AmericasHealth Plan will retain the right to revoke delegation.