Truescripts Participating Pharmacy Credentialing Policy
Credentialing is a process to obtain, verify and assess and confirm the qualifications of healthcare providers to provide patient care services. It is the policy of Truescripts, to certify and recertify the credentials, patient care quality all Participating Pharmacies using the standards set out in this policy.
Standards
Credentialing Standards In order to qualify as a Participating Pharmacy for Truescripts networks, the Pharmacy must meet the following current standards:
- Valid State Pharmacy and/or Business License(s)
- DEA Certification
- CDS Certification
- Completed and signed Retail Pharmacy Agreement
- Professional Liability Insurance Certificate of Coverage
- W-9 Completed Form(s) required each different Tax ID number
- Compliance with the Retail Pharmacy Agreement and all requirements for plan administration
- Attestations for Security, Education Certification
- Satisfactory History of Professional Conduct including any sanctions
- Healthcare credential(s), Board Certification(s), or State-specific credentialing requirements.
Verification TrueScripts’s Relations Network Support staff will verify the information on the Retail Pharmacy Agreement using all available public sources, direct contact verification, and the following resources:
Once verified, Truescripts’ s pharmacy support staff will determine if the Participating Pharmacy is eligible to participate in Truescripts Pharmacy Network.
Note: Truescripts retains the right to terminate a Participating Pharmacy in any of our Pharmacy networks when a Participating Pharmacy breaches the covenants of the Retail Pharmacy Agreement; engages in any fraudulent activity.
Approval
If the determination is to approve the submitted application, Pharmacy support staff will:
- Recommend approval.
- Update Truescripts Participating Pharmacy Network Systems with all applicable information.
Incomplete Participating Pharmacy Agreement
If the Retail Pharmacy Agreement is incomplete, pharmacy support staff will contact the Pharmacy and offer the opportunity to correct any deficiencies or to provide supplemental information. If the Pharmacy fails to correct the incomplete Retail Pharmacy Agreement within thirty (30) calendar days of notice, the application is placed on hold and will be returned to the Pharmacy or destroyed.
Non-Approval
If the application is not approved, the Pharmacy support staff will:
- Recommend denial.
- Send the Pharmacy a denial letter specifying the reasons why the application was not approved. The denial letter will contain the Pharmacy’s appeal rights.
- Pharmacy must address the reasons provided in the Letter of Non-approval with documentation and explanation to TrueScripts Director of Pharmacy Operations within thirty (30) calendar days of the delivery of the letter.
Appeals Process
If the Pharmacy disagrees with the credentialing determination, the Pharmacy may request an appeal by submitting a written request to the Truescripts Director of Pharmacy Operations at the following address:
TrueScripts
513 E South St.
Washington, IN 47501
Attn: Director of Pharmacy Operations
The formal appeal request must be written and submitted within thirty (30) days of the notification of the rejected application. The Director of Pharmacy Operations will review the requested Appeal on the current record and decide to affirm or reverse the denial decision. The determination shall be submitted in writing to the Pharmacy within thirty (30) days.
Re-credentialing
Re-credentialing will occur on a one (1) or two (2) year cycles, dependent on the state the license was issued, or at any time adverse information is obtained about a Participating Pharmacy. Re-credentialing will follow the same standards and processes outlined above, and will consider patient satisfaction, contract and plan administration compliance, member access needs, onsite visitation, and other Participating Pharmacy agreement updates during the participation period.
- Re-credentialing review will include, but not be limited to – Quality, Cost, Administrative Compliance, Member Complaints (if applicable), etc.
- Should a negative re-credentialing decision be made by the Director of Pharmacy Operations, the Participating Pharmacy may appeal the decision to the Vice President of the Pharmacy Network Development or his/her equivalent for review.
Corrective Action
- After participation has been granted, Provider Relations Network Support staff will monitor the performance of the Participating Pharmacy. Should adverse information be obtained regarding the items verified in the credentialing process, patient satisfaction, quality, cost, and/or administrative compliance, the Provider Relations Network Support staff will investigate these findings. The purpose of this investigation is to confirm the information obtained. This research is done through various outlets, as stated in the verification process above, as well as other resources if available and applicable (i.e., member surveys, complaints, etc.).
- Upon completion of the investigation by the Network Support Staff, if the information obtained is found to be true, the Provider Relations Network Support staff will recommend to the Director of Pharmacy Operations a disciplinary action depending upon the severity of the findings. Truescripts will require a Corrective Action Plan (“CAP”) with the Pharmacy, and could require further actions which may include, but limited to, the following:
- Audit of Participating Pharmacy member claims.
- Participating Pharmacy written warning of non-compliance.
- Termination of Participating Pharmacy.
- Provider Relations Network Support staff will forward the Participating Pharmacy file to the Director of Pharmacy Operations.
- Within thirty (30) days of the Professional Relations Network Support staff recommendation, the Director of Pharmacy Operations will determine whether to affirm, reverse or modify the recommendation. The Director’s determinations will be sent to the Participating Pharmacy, in writing, within a 30-day period.
- The Participating Pharmacy has the right to appeal against the decision of the Manager of Quality Assurance to the Credentialing Committee or its Sub-committee, within thirty (30) days of receipt of the decision.
- All documentation will be stored as required for applicable laws.
Delegation
- Any delegate of credentialing authority must meet the same or comparable standards to be qualified for delegation of credentialing and approved by the Director of Pharmacy Operations.
- All entities responsible for credentialing are subject to the terms of the Retail Pharmacy Agreement and terms of the prescription benefit coverage.
- All delegated entities will provide a copy of their credentialing standards of the organization.
- All delegated entities will report to Truescripts any negative findings within 30 days of the finding.
