SP credentials its Network Providers in accordance with the standards and guidelines of the National Committee for Quality Assurance (NCQA), and other accrediting or regulatory agencies, as appropriate. The doctor network consists of Optometrists, Ophthalmologists and Doctors of Osteopathy and each is required to be an active participant in the Medicare program.

Confidentiality

VSP maintains confidentiality of all information obtained for the purposes of credentialing and recredentialing VSP doctors. Only staff in Network Development, the Credentialing Committee and delegated entity(ies) have access to this confidential doctor information. VSP does not disclose confidential doctor information to any person or entity except with the written permission of the doctor or as otherwise permitted, required by contract or State and/or Federal law.

Delegation of Primary Source Verification

VSP delegates the administrative activities of its credentialing to an NCQA certified Credentialing Verification Organization (CVO).

In accordance with NCQA standards, the CVO verifies the presence and timelines of the following:

• Timeliness of current attestation
• All active state licenses
• Board certification of MDs and DOs
• Education and training
• DEA license as required by applicable State regulation
• CDS, if applicable
• Current individual doctor malpractice insurance coverage
• Malpractice claims history and/or sanctions
• Medicare/Medicaid sanctions via National Practitioner Database, (NPDB), Office of the Inspector General (OIG) and System for Award Management (SAM)
• State Medicaid enrollment including State Agency suspension, exclusions and terminations list, if applicable
• Hospital privileges loss or limitation of privileges
• Work history for initial applications only—application or curriculum vitae
• Medicare opt out
• Query the SSA Master Death
• National Plan and Provider Enumeration System (NPPES) – NPI number
• Office of Foreign Asset Control (OFAC)
• CMS Preclusion List

Medicare participation is required of all VSP network doctors in order to comply with the implementation of the Centers for Medicare and Medicaid Services’ (CMS) Medicare Advantage program. VSP doctors are required to provide evidence of participation at initial and re-credentialing.

Application

All applicant and existing doctors must complete and attest to the accuracy of their CAQH information and consent to the inspection of records and documents pertinent to the credentialing and recredentialing processes.

Doctors must complete the CAQH application, or State-mandated application, that includes a current and signed attestation of the following:

• Physical and mental status
• Lack of impairment due to chemical dependency/substance abuse
• History of loss of license and/or felony convictions
• History of loss or limitation of privileges or disciplinary activity
• Current malpractice insurance coverage
• The correctness and completeness of the application

Doctor Rights Regarding Application

Doctors have the right to request the status of their credentialing and recredentialing application. The doctor’s rights and VSP contact information is included in the Provider Reference Manual for existing providers and online at vspglobal.com for applicant doctors. The doctor can request, in writing, to review and correct information obtained from outside sources for the purposes of initial credentialing and recredentialing. Doctors may submit their request via email to credentialing@vsp.com. VSP will respond within 3-5 business days. Peer review information is confidential and protected. The doctor application for VSP participation includes this provision.

Doctor Notification of Information Discrepancy

If the information submitted by the doctor varies substantially from the primary source verification and/or VSP network requirements, VSP or its CVO will make multiple contacts to inform the doctor via mail, facsimile, or phone call. Failure to correct the information may result in a denial and/or termination from the VSP network.

Doctor Failure to Disclose Adverse Information

VSP applicant and existing doctors must provide complete and accurate information. If the doctor fails to disclose adverse actions, VSP or its CVO will make multiple contacts with the doctor electronically, by facsimile.

Non-Discrimination

The Credentialing Committee members sign a non-discrimination agreement that remains in effect during their term as a Committee member. The statement attests that all decisions made by the committee are based on the doctor’s credentials and VSP network participation criteria and not the doctor’s age, gender, sexual orientation, race, ethnic/national identity, specialization or special services the doctor may provide.

Credentialing and Recredentialing Timeframes

The credentialing and recredentialing process follows these timeframes:

• All source verification occurs within 180 calendar days of doctor signature date and Credentialing Committee date.
• CVO notifies the applicant doctor electronically, by facsimile or by certified mail, return receipt requested within 30 calendar days of receipt if application is incomplete.
• VSP notifies applicant doctors of Credentialing Committee approval and all doctors of Credentialing Committee denial within 10 business days of Committee decision.
• Recredentialing of doctors occurs with thirty-six (36) months of prior credentialing date in accordance with state and federal requirements and NCQA guidelines.

Additional VSP Network Participation Requirements

• All VSP services must be provided by a network doctor at a qualified office location. Each office location and doctor connected to the applicant doctor must be credentialed by VSP and meet network participation criteria.
• Each practice must have internet access to submit claims electronically and provide a valid e-mail address to receive communications from VSP.
• Each practice must be able to receive claim payment under one Tax Identification Number, electronically, via direct deposit.
• Use VSP contracted laboratories, as required based upon a patient’s VSP plan type (except, this shall not apply to doctors who practice in states with laws that specifically prohibit a health plan such as VSP from requiring the provision of such services).
• Maintain and display a minimum inventory of 200 frames from approved frame manufacturers, including a minimum of 100 frames that fall within the average VSP frame allowance of $150.
• Provide contact lens care to VSP patients.
• Provide 24-hour access to VSP patients, as well as have 24-hour access to instrumentation and materials. The 24-hour access to patients must include one or more of the following options:
  • (a) answering service,
  • (b) on-call service,
  • (c) pager/mobile phone or
  • (d) answering machine message providing the patient with instructions on how and where to obtain services from a VSP doctor, and instructions on what to do in case of a medical emergency.

All of these options must allow a patient to leave a message for a returned call back.

• Provide service to patients who have the VSP Choice Plan or the VSP Advantage Plan (except, that this shall not apply to doctors who practice in states with laws that specifically prohibit a health plan such as VSP from requiring the provision of such services).
• VSP’s primary method of communication is e-mail. At least one network doctor’s valid e-mail address is required for each Qualified Office Location. It is the network doctor’s responsibility to maintain an up-to-date e-mail address to ensure receipt of important updates and critical information from VSP.