A Guide to Provider Credentialing with PacificSource

PacificSource consists of several components that work together to serve members:

• PacificSource Health Plans (the insurance component offering commercial and government plans)
• PacificSource Community Health Plans (focused on Medicaid managed care)
• PacificSource Administrators (third-party administration services)
  

PacificSource offers several pathways for provider participation in their network, each with distinct credentialing requirements and operational expectations:

• Network Providers: Independent practitioners or groups who contract directly with PacificSource to provide services to members at negotiated rates. These providers typically represent the majority of PacificSource’s network and have the most direct contractual relationship with the organization.
• Specialty Providers: Healthcare professionals who provide specialized services that may not be available from primary care providers or general specialists within PacificSource’s standard network. These providers often work on a referral basis and may have more flexible credentialing requirements.
• Ancillary Service Providers: Organizations and professionals who provide support services such as laboratory testing, diagnostic imaging, durable medical equipment, or home healthcare services. These providers have specialized credentialing requirements related to their specific service areas.
• Facility-Based Providers: Healthcare professionals who practice primarily within hospital or institutional settings. Their credentialing often involves coordination with the facilities where they practice and may include specific requirements related to hospital privileges and institutional affiliations.
  

The credentialing process typically follows these key phases:

Initial Application and Documentation Review

The credentialing journey begins with a detailed application that requires providers to submit extensive information about their professional background, education, training, and current practice operations. PacificSource’s application process emphasizes accuracy and completeness, as incomplete applications can significantly delay processing times.

Providers must submit documentation including educational credentials, training certificates, licensing information, insurance coverage details, and professional references. The organization places particular emphasis on ensuring all submitted information is current and accurately reflects the provider’s qualifications and practice status.

Primary Source Verification

PacificSource conducts thorough primary source verification of all submitted credentials, directly contacting institutions and organizations to confirm the accuracy of provider information.

This verification process includes:

• Medical education verification through degree-granting institutions
• Residency and fellowship training confirmation
• Board certification verification through appropriate specialty boards
• State medical license verification and status confirmation
• DEA registration confirmation and current status
• Malpractice insurance coverage verification
• Professional liability history review
• Hospital privilege verification where applicable
• National Practitioner Data Bank inquiry
• Office of Inspector General exclusion screening

Peer Review and Clinical Assessment

PacificSource’s credentialing committee, composed of practicing physicians and healthcare professionals, reviews each application and the results of primary source verification. This committee evaluates providers based on their qualifications, practice patterns, professional conduct, and alignment with PacificSource’s quality standards.

The peer review process examines factors such as clinical competency, professional behavior, adherence to evidence-based practice guidelines, and commitment to patient-centered care. Committee members may request additional information or clarification during their review process.

Practice Assessment and Site Evaluation

For certain provider types and practice situations, PacificSource may conduct practice site assessments to evaluate the physical facilities, medical record keeping systems, patient safety protocols, and overall practice operations. These assessments help ensure that credentialed providers can deliver appropriate care in suitable environments.

Site evaluations typically examine accessibility compliance, infection control procedures, medical record security, emergency protocols, and staff qualifications. Providers should be prepared to demonstrate their commitment to maintaining high-quality practice environments that meet PacificSource’s standards.

Final Credentialing Decision

After completing all verification and review processes, PacificSource’s credentialing committee makes a final determination regarding the provider’s application. Possible outcomes include full approval, conditional approval with specific requirements, or application denial.

Approved providers receive notification of their credentialing status and information about next steps for contract execution and network participation. The organization provides guidance on accessing provider resources, understanding payment procedures, and meeting ongoing performance expectations.

Ongoing Monitoring and Recredentialing

PacificSource requires recredentialing every three years to ensure providers continue meeting the organization’s standards and maintaining their professional credentials. The recredentialing process involves updating information, verifying continued license and certification status, and reviewing performance metrics from the preceding credentialing period.

Between formal recredentialing cycles, PacificSource monitors provider performance through various quality metrics, member feedback, and ongoing verification of key credentials such as licensing and malpractice insurance.

Education and Training Standards

PacificSource requires providers to meet established educational and training standards that demonstrate their preparation for independent practice:

• Graduation from accredited medical schools or appropriate professional training programs
• Completion of approved residency programs in the specialty area where the provider will practice
• Fellowship training completion where required for subspecialty practice
• Current board certification or documented progress toward certification within established timeframes
• Continuing medical education compliance with state requirements and specialty board standards

Licensure and Professional Certification Requirements

All credentialed providers must maintain current, unrestricted professional licenses and certifications:

• Active, unrestricted state medical license in the jurisdiction where services will be provided
• Current DEA registration for providers prescribing controlled substances
• Professional liability insurance meeting PacificSource’s minimum coverage requirements
• Specialty board certification appropriate to the provider’s practice area
• Any additional certifications required for specific service areas or specialties

Professional Conduct and Quality Standards

PacificSource evaluates providers based on their professional conduct history and commitment to quality care delivery:

• Clear professional conduct record with no significant disciplinary actions
• No exclusions from federal healthcare programs or other insurance networks
• Demonstrated adherence to clinical practice guidelines and quality standards
• Commitment to patient-centered care and member satisfaction
• Willingness to participate in quality improvement initiatives and performance monitoring
  

• Oregon Operations: As PacificSource’s founding state, Oregon represents the organization’s largest market with established provider networks and mature operational systems. Oregon providers benefit from well-developed support systems and established referral patterns.
• Washington Presence: PacificSource’s Washington operations focus on serving specific geographic regions and member populations. Providers in Washington should be familiar with state-specific regulatory requirements and PacificSource’s particular network needs in their service areas.
• Idaho and Montana Markets: These markets represent growth opportunities for PacificSource, with potential for providers to establish strong positions within developing networks. Providers in these states may find more opportunities for network participation, particularly in underserved geographic areas.
  

Steps for maximizing CAQH effectiveness with PacificSource:

• Establish and maintain a current CAQH ProView profile with complete, accurate information
• Grant PacificSource authorization to access your CAQH data during the application process
• Regularly update your CAQH profile to reflect any changes in credentials, practice information, or professional status
• Monitor your CAQH profile for expiration dates and renewal requirements
• Use CAQH’s document upload features to provide supporting documentation
  

PacificSource offers various online resources and technology platforms to support credentialed providers in managing their relationships with the organization:

• Provider Portal Access: PacificSource maintains online portals where credentialed providers can access important information and complete routine tasks including checking credentialing status, updating practice information, accessing clinical resources and guidelines, submitting claims and checking payment status, and communicating with PacificSource representatives.
• Clinical Resources: The organization provides credentialed providers with access to clinical practice guidelines, quality metrics, formulary information, and other resources designed to support high-quality care delivery and efficient practice operations.
• Administrative Support: PacificSource offers various forms of administrative support to help providers manage their network participation effectively, including assistance with prior authorization requirements, claims processing guidance, and resolution of operational issues.
  

However, actual processing times can vary based on several factors:

• Application Completeness: Complete, accurate applications with all required documentation process more quickly than incomplete submissions requiring additional information requests.
• Verification Complexity: Providers with extensive practice histories, multiple licenses, or international training may experience longer verification timelines as primary sources require more time to confirm credentials.
• Committee Meeting Schedules: Credentialing committee meetings occur on regular schedules, and applications must be ready for review by specific deadlines to be considered at upcoming meetings.
• Regional Variations: Different PacificSource markets may have varying processing capabilities and timelines based on application volumes and regional staffing levels.
• Specialty-Specific Requirements: Certain specialties or practice types may require additional review steps or specialized evaluation processes that extend the overall timeline.
  

Pre-Application Preparation

Research PacificSource’s network needs in your geographic area and specialty to align your application with organizational priorities. Review current provider directories to identify potential gaps in coverage that your services could address.

Gather all required documentation well in advance of application submission, ensuring that all materials are current and properly formatted. Create a checklist to verify that all required elements are included before submission.

Update your CAQH ProView profile completely and verify that all information is accurate and current. Ensure that all uploaded documents are legible and properly labeled for easy identification during the review process.

During the Application Process

Complete all application materials thoroughly and accurately, paying particular attention to ensuring consistency across all submitted documents. Inconsistencies or discrepancies can raise questions and delay processing.

Respond promptly to any requests for additional information or clarification from PacificSource credentialing staff. Maintain regular communication and provide updates if any of your credentials or practice information changes during the review process.

Monitor your application status through available tracking systems and maintain appropriate follow-up without being overly demanding of credentialing staff time and attention.

Post-Approval Integration

Complete all required orientation activities and familiarize yourself with PacificSource’s systems, policies, and procedures for network providers. Take advantage of available training resources to optimize your effectiveness as a network participant.

Establish effective working relationships with PacificSource representatives and other network providers in your area. These relationships can provide valuable support and referral opportunities.

Implement systems to track and meet ongoing performance expectations, quality metrics, and administrative requirements associated with network participation.

Primary Care Providers

Primary care providers represent a crucial component of PacificSource’s network strategy, as they serve as the foundation for coordinated care delivery and cost-effective healthcare management.

Primary care credentialing may emphasize factors such as preventive care capabilities, care coordination experience, and willingness to serve diverse patient populations. Providers should be prepared to demonstrate their commitment to primary care delivery and population health management.

Specialist Providers

Specialists must demonstrate not only clinical expertise in their specialty areas but also willingness to work collaboratively with primary care providers and other network participants.

Specialist credentialing often requires documentation of board certification, subspecialty training, and experience with the specific services and procedures they plan to provide to PacificSource members. Some specialties may have additional requirements related to facility privileges or equipment access.

Behavioral Health Providers

Behavioral health and substance abuse treatment providers face specific credentialing requirements related to their specialized services and the regulatory environment surrounding behavioral healthcare.

These providers should be prepared to document their training in evidence-based treatment approaches, experience with diverse patient populations, and compliance with applicable state and federal regulations governing behavioral health services.

Facility-Based and Ancillary Providers

Providers who deliver services primarily within institutional settings or who provide ancillary services such as diagnostic testing or durable medical equipment have specialized credentialing pathways.

These providers often need to demonstrate their facilities meet appropriate standards, their staff possess required qualifications, and their operations comply with applicable regulatory requirements and quality standards.

• Documentation Issues: If questions arise about your credentials or practice history, provide clear, complete responses with supporting documentation. Address any concerns proactively and honestly, providing context where appropriate.
• Processing Delays: If your application experiences unexpected delays, maintain professional communication with credentialing staff while advocating appropriately for timely processing. Offer to provide additional information or clarification that might expedite review.
• Application Denials: In the event of an unfavorable credentialing decision, request specific feedback about the reasons and inquire about opportunities for reconsideration or reapplication. Use any feedback provided to strengthen future applications.
• Appeals Process: PacificSource maintains formal appeals processes for providers who believe their applications were evaluated incorrectly. Follow established procedures and provide any additional information that might influence reconsideration of the decision.