Practitioner Rights

Upon written request, practitioners have the right to:

  • Review Tufts Health Plan’s credentialing policies and procedures
  • Be informed of the status of their credentialing or recredentialing application
  • Review information submitted to Tufts Health Plan for purposes of credentialing or recredentialing the practitioner, including information obtained by Tufts Health Plan from any outside primary source, such as a malpractice carrier, state license board, or the National Practitioner Databank (NPDB). Tufts Health Plan is not required to reveal the source of information if the information was not obtained for the purpose of meeting Tufts Health Plan’s credentialing requirements.  Practitioners are not entitled to review references, recommendations, information that is peer-review privileged or information which by law Tufts Health Plan is prohibited from disclosing.
  • Be notified by Tufts Health Plan in the event that credentialing information that it has obtained from sources other than the practitioner varies substantially from credentialing information provided to Tufts Health Plan by the practitioner. Tufts Health Plan is not required to reveal the source or contents of the information if the information is not obtained for the purpose of meeting Tufts Health Plan’s credentialing requirements.
  • Review any information submitted in support of the credentialing application and to correct erroneous information other parties provide (excluding peer-review information). Submit corrections to the Credentialing Department within 10 days of receipt by emailing Tufts_Health_Plan_Credentialing_Department@tufts-health.com.

Note:

  • There is no right of appeal from an initial credentialing determination by the Quality of Care Committee (QOCC), except when required by applicable state or federal law.
  • In the event the QOCC votes to take disciplinary action, the practitioner is entitled to notice consisting of a written statement of the reasons for the action and, if applicable, has the right to appeal such action by filing a written appeal within thirty (30) calendar days of receipt of the statement of reasons.

Additional rights for Rhode Island practitioners

  • The practitioner will receive a response from Tufts Health Plan regarding the application within 180 calendar days after receipt of the application.
  • If a credentialing decision is made to deny credentials to a practitioner, the QOCC will send the practitioner written notification of all reasons for the denial within sixty (60) calendar days of receipt of the completed and verified application.
  • If the QOCC votes to take disciplinary action against a practitioner, the practitioner shall have thirty (30) calendar days from the receipt of the letter from the QOCC to notify Tufts Health Plan in writing that they will appeal the QOCC decision. If the practitioner exercises their appeal right, Chair of the QOCC will arrange for a hearing before an Appeals Committee that shall review the decision of the QOCC and issue a decision prior to implementation of the disciplinary action against the practitioner. The process outlined in the Tufts Health Plan appeals process will be followed.
  • If requested in writing by a practitioner whose credentials have been revoked or adversely modified, the due process outlined in the Tufts Health Plan appeals process shall be waived.