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Membership Process

Hospital Staff Privileges are a requirement unless not clinically indicated.  All members must have fully inpatient, non-probationary active staff privileges at the practitioner's primary inpatient admitting JCAHO facility within the PCOT service area.

Active staff privileges must be maintained to participate in PCOT.  Staff category changes must be reported to PCOT within 10 days.

Credentialing includes an on-site office review for all members.  Your cooperation with the PCOT Credentialing staff to schedule an office site visit assures timely processing of your membership application.

Membership Approval Process

    Membership Approval follows the completed credentialing process. The PCOT Credentialing Committee and Board of Directors will then consider the application. When the PCOT Board of Directors approves an applicant, he/she is immediately eligible to sign a participation agreement with PCOT. A PCOT Physician Services Representative will schedule an appointment to assist the new member in the selection of managed care plans.

    If an applicant is not approved for the PCOT membership, the applicant will be notified of the reason(s).  There are opportunities to appeal this decision.

    An applicant will be rejected unless all physicians participating in the applicant's group are current with all payments to the PCOT.

    Automatic revocation of PCOT membership and payor contracts occur if any payment to PCOT is 90 days past due.

    Recredentialing is essential towards maintaining your participation status in PCOT. PCOT will recredential its physicians in accordance with TDI and NCQA standards. This process is accomplished every two years.

Credentialing Timeline

    Logging

    • If application is complete: PCOT logs application and enters demographics into electronic system.  Application is forwarded to the credentialing CVO within one business day.

    • If application is incomplete: PCOT returns application to physician and executes follow-up ticker mechanism in database.

    Credentialing

    • Enter data with accompanying credentials (licensure)

    • Create index file

    • Run on-line verifications

    • Audit verifications

    • Prepare for Medical Director and Peer Review Committee

    Approval

    • PCOT Credentialing Committee approve/deny credentialing and membership, while the Board of Directors oversees Credentialing Committee decision.
    Payor/Plans

    • PCOT Physician Services Representative delivers opt in/opt out packages to physicians.

    • Physician completes and returns information.

    • PCOT enters data and notifies Health Plan(s)

    • PCOT sends notice letter/list with current profile to payors.

    PCOT is not responsible for the following delays:

    • Failure by the physician to provide completed application (including all supporting documents) in a timely manner

    • Failure by the physician to obtain adequate hospital privileges (as described in Summary)

    • Postponement of board meeting(s) (thus membership decision)

    • Failure by physician to return opt in/opt out packages on time

    • Failure by Health Plan(s) to assign/enter effective dates into their system and to notify PCOT in a timely manner

The response times by the providers, the hospital, the Board, and the Health Plan(s) are all variables comprising the timeline, none of which PCOT can control.  On average, the entire application process (from time of application to date of acceptance) for PCOT is less than 60 days.


1 - 2 months 1 week 1 - 2 months
Credentialing/PRC Board Submission to Health Plans > Effective date


 
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