Network Health is responsible for ensuring, to the extent possible, members receive high-quality care from our provider network. We review and assess provider practices to ensure a quality network. We reserve the right to deny or alter a contractual relationship when a provider fails to meet our quality standards.
In the event there is adverse information, disciplinary action, a sanction, or other serious quality concerns about a provider, Network Health's Credentialing Committee reviews the information to determine if a provider's contract status should be denied, suspended, or terminated.
You have the right to appeal the decision of the Credentialing Committee. You must request any such Appeal in writing, and we must receive the request within 60 days of your receipt of the notice of Adverse Determination. Incomplete applications, or applications of providers who no longer meet credentialing criteria due to loss of license, loss of board certification, or loss of DEA license, are not subject to appeal.
Reconsideration of initial recommendation
If you do not agree with the Credentialing Committee's initial recommendation, you may request Reconsideration. You must submit a signed letter explaining why you believe the decision was incorrect and include any new or additional information you would like the Credentialing Committee to consider. The Credentialing Committee will discuss your Reconsideration at their next meeting, review all information, and vote to sustain, modify, or overturn its original decision.
If you do not agree with the Credentialing Committee's initial recommendation or Reconsideration decision, you may request an appeal hearing before the Appeals Advisory Committee. You must submit a signed letter explaining why you believe the Credentialing Committee's decision was incorrect, and include any new or additional information you would like the Appeals Advisory Committee to consider.
We will notify you of the appeals hearing date. You may have an attorney, advocate, or other support person present if you wish. You will have 20 minutes to present relevant information about the issues and facts surrounding the basis for the Credentialing Committee's decision.
The Appeals Advisory Committee is comprised of three independent physicians who did not participate in the initial decision. Network Health's Medical Advisory Committee appoints the Appeals Advisory Committee. One of these physicians will be in the same or like specialty as you. The Appeals Advisory Committee will make a formal recommendation to the Credentialing Committee about the decision to accept or reject your application, suspension, or termination. If the Appeals Advisory Committee's findings do not result in a recommendation to reverse the Credentialing Committee's initial decision, the Credentialing Committee's decision will be final. We will notify you within five (5) business days of the Credentialing Committee's final decision.
Please send correspondence to:
Attn: Credentialing Supervisor
101 Station Landing, Fourth Floor
Medford, MA 02155