Medical provider network

1. Janet Peterson Program Manager, Health Services Analysis Medical provider network

2. Network Status and Processing • Network Denial Process • Credentialing based on WAC criteria for minimum standards • Review and recommendation by external, peer credentialing committee • Recommendation reviewed by Medical Director for initial decision • Network Denial Status • About 60 providers have had an initial denial decision • Most request reconsideration – 60 day timeframe to request and up to 90 day to respond • Reconsideration subject to peer review and medical director review • Final Agency Decision • No treatment/payment after effective date • Several settlements in process • Board or litigation – three in appeal

3. Network Criteria Summary WAC 296-20-01030/01050

4. Status of denied applications – through April 18, 2013 Denials are effective 60 days from provider’s initial notification unless the provider requests reconsideration. We expect additional denials to arise as we continue to review more applications.

5. MPN Statistics – Denial Process Data Types of Denied Providers **Applications often have more than one issue A. Clinical Care B. Compliance with Clinical Guidelines C. Criminal Misconduct, Substance Abuse, Sexual Misconduct D. License Issues E. Misrepresentations and Omissions F. Payer or Institutional Privileges