CCPA Credentialing Responsibilities

Why does CCPA credential its members?  CCPA has delegated agreements with multiple managed care payors.  Meaning that the managed care payors give CCPA the authority and responsibility to perform the credentialing and recredentialing on the physicians who are members of CCPA on their behalf.  The agreement includes the managed care expectations of the credentialing and recredentialing performed by CCPA and may reference state, federal, and regulatory body requirements. 

Annual Audits - Managed care payors also conduct annual audits of the delegated tasks to ensure full compliance of all regulations are completed by CCPA in a timely matter. Therefore, all CCPA members are required to complete the CCPA credentialing/recredentialing process and be approved by the CCPA credentialing committee within the regulatory time frame.  

Credentialing is not just for managed care payors agreements.  The number one reason why CCPA credential’s its members is for patient safety.   CCPA wants to ensure that our members provide high quality patient care, so credentialing is a way to evaluate providers’ treatment of patients.  Moreover, risk management concerns is also why health care organizations credential clinicians.  By credentialing all providers, hospitals/practices can discover if a provider has problems/unresolved issues with his/her patient care.

As mentioned above, CCPA credentials providers because it is required by our delegated agreements with managed care payors.  However, other healthcare organizations credential providers because it is required by accrediting and regulatory agencies. In order to participate in Medicare, Medicaid and other federal/state programs, hospitals/practices are required to meet the Medicare Conditions of Participation requirements.  These requirements are located in the Code of Federal Regulations and are enforced to protect patients' health and safety and to ensure quality care for all hospital patients.

Accreditation and Regulatory Entities

There are a few accreditation and regulatory entities that set standards for all health care organizations.  The entities are listed below with a brief description; please click on the entities’ name to find out more about their standards. 

CCPA adheres to one of the primary accreditors for managed care, which is the National Committee for Quality Assurance (NCQA).  NCQA manages voluntary accreditation programs for independent physicians, health plans, and medical groups.  NCQA also certifies credentialing verification organizations (CVO) such as Children’s Faculty Practice Plan (FPP).  A CVO is an organization that gathers information and verifies providers credentials to assist health plans and other health care services with their primary source verification needs. 

URAC accredits health organizations that includes medical management organizations, health plans and hospitals and health websites.

The Accreditation Association for Ambulatory Health Care (AAAHC) accredits ambulatory health care organizations, including ambulatory surgery centers, office-based surgery centers, endoscopy centers and college students’ health centers.  AAAHC also accredits managed care organizations such as HMOs and PPOs.

The accreditation and regulatory bodies that creates standards for hospitals and other healthcare organizations and addresses The Center for Medicare & Medicaid Services (CMS) standards and regulations are listed below.

  • The Joint Commission (TJC) accredits hospitals, ambulatory care, surgery, rehab and long-term care facilities.  Ann & Robert H. Lurie Children’s Hospital of Chicago’s Medical/Dental Office Staff adheres to TJC accreditation standards.

  • Healthcare Facilities Accreditation Program (HFAP) has joined the Accreditation Commission for Health Care (ACHC) in accrediting acute care hospitals, ambulatory care, ambulatory surgery centers, behavioral health centers, clinical laboratories, critical access hospitals, dentistry, home health, home infusions therapy, hospice, office-based surgery, palliative care, pharmacy, private duty, renal dialysis, and sleep therapy. 

  • DNV Hospital Accreditation (DNV) accredits hospitals and certify health programs that meet or exceed clinical readiness and patient safety standards.