South Atlantic Medical Group’s credentialing staff, in conjunction with the quality management staff, provide information to the Credentialing Committee to determine benchmarks for panel acceptance.

The Medical Director maintains substantial involvement in the Credentialing Program and is responsible for ensuring that the Credentialing Program is properly developed, implemented and coordinated and is substantially involved in the function of the Program, including membership on the Credentialing Committee. Responsibility for the Program is delineated in the Medical Director Position Description.

The Credentials Committee shall establish objective criteria for the addition of new practitioners to the Provider Network. These criteria include basic guidelines such as requirements for licensure, hospital privileges, DEA certificate, education and training, malpractice insurance, as well as acceptable standards for liability history. Other objective considerations may be incorporated into criteria.

Monitoring is required to ensure the firm is not credentialing or paying debarred or suspended providers for services. This check is done when initialing contracting practitioners, and then on a monthly basis thereafter to ensure claims for suspended or debarred providers are not paid. Non-participating providers are also checked in the same manner.

In compliance with the OIG and Section 50.6.8 of the Medicare Managed Care Manual, South Atlantic Medical Group will check the OIG Excluded Individuals/Entities (LEIE) and the System for Award Management Exclusions List (SAM) as follows:

1. The following individuals will be screened prior to hiring or contracting:
• New or temporary employees
• Volunteers
• Consultants
• Governing body members
• FDRs
• Contracted providers
2. Non-Contracted providers will be screened prior to the authorization of services.
3. Ongoing monitoring will be conducted monthly for all employees, temporary staff, volunteers, consultants, management, administrative staff, governing body members, FDRs, and contracted
   and non-contracted providers to ensure none of these persons or entities are excluded or become excluded from participation in federal programs.
   • If an individual or entity is initially screened against the entire LEIE/SAM and Medicare State Opt-Out list at the time of hire/contract, then monthly monitor need only include
     the supplemental file provided each month which lists the entities added to the list.
   • The Provider Network staff screen providers on every occasion before services have been rendered and before issuing an LOA or MOU.
   • When screening, the Provider Network screens the full name and Date of Birth of individuals.
   • A log is kept of all screenings conducted which includes dates of screening and other pertinent information. Screen shots may also be included with the log file.
4. Any individual or entity listed on the exclusion list will immediately be removed from the delegated function.