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Credentialing

Credentialing

All practitioners applying for participation in the Gateway Health Alliance network must meet the credentialing criteria, unless an exception is made by the Credentialing Committee. 

All practitioners applying for initial and continued participation in the Gateway network must also meet all applicable criteria as outlined below:

  • Have completed a Credentialing Application or a CAQH Provider Data Form and a current attestation statement.
  • Have current, unrestricted state license in Virginia, and/or North Carolina.
  • Be Board Certified in the primary specialty for which the physician in applying. The acceptance of a non-board certified physician might occur when it is determined.
  • No board certified physicians are available or other exceptions of waiver requirements are met.
  • Board Certification was not available at the time the physician entered practice.

At the time of recredentialing, PCPs must perform adequately when information pertaining to member complaints, member satisfaction, utilization management, and/or results of quality improvement activities are evaluated.                                                                                                                                                         

Recredentialing Requirements

Gateway re-credentials providers every three years.  We verify that the physician has a current medical license, active medical malpractice coverage, hospital privileges, and board certification.  Medical malpractice claims filed during the last three years are reviewed.  Quality Improvement issues, Utilization Management issues, and member complaints are also considered during this process.  Decisions about re-credentialing are made by Gateway’s Medical Management Committee.

 

Do you have questions about the Credentialing process? 

Contact John Holshouser, Director of Provider Operations, at 1-800-656-1260

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