Credentialing

Gold Coast Health Plan (GCHP) is committed to ensuring access to a high-quality health care delivery system. We contract with high-quality institutions, practitioners and allied health professionals to ensure that members receive quality health care and services.

The Credentials Committee is responsible for decision making related to the credentialing and recredentialing of health care practitioners and organizational providers. GCHP conducts each Credentials and Peer Review Committee meeting in a non-discriminatory manner. No practitioner will be denied privileges with GCHP, have any corrective actions imposed, or have their privileges suspended or terminated solely on the basis of race, ethnic / national identity, age, gender, sexual orientation, or the type of patient that the practitioner treats, including those from high-risk populations or with conditions that require costly treatment.

All credentialing and recredentialing is performed in accordance with state Department of Health Care Services (DHCS) regulatory requirements and National Committee for Quality Assurance (NCQA) standards and guidelines. Credentialing documents are obtained through the Council for Affordable Quality Healthcare (CAQH). Practitioners who do not have a CAQH file may be required to complete a Practitioner Credentialing Application. Gemini Diversified Services, a credentialing verification organization, assists in conducting primary source verification, data collection and reporting services.

Practitioners must be qualified in accordance with current applicable legal, professional, and technical standards and appropriately licensed, certified or registered. Practitioners must have good standing in the Medicare and Medicaid / Medi-Cal programs and must be enrolled in Medi-Cal. Practitioners who have been terminated from either Medicare or Medicaid / Medi-Cal cannot participate in GCHP's network.

GCHP may delegate specific credentialing and recredentialing responsibilities to qualified entities. GCHP will evaluate the entity’s capacity to perform the activities prior to delegation. GCHP retains the right, based on quality issues, to approve, suspend, or terminate practitioners and sites of care.

Applying for Credentialing

For initial practitioner credentialing and organizational provider credentialing applications, contact GCHP's Contracting Department at ProviderContracting@goldchp.org to obtain a credentialing application. Practitioner and organizational recredentialing applicants may inquire through GCHP's Credentialing Department at Credentialing@goldchp.org.

GCHP Policies and Procedures:

• Practitioner Credentialing Policy
• Credentialing for Organizational Providers Policy
• Fair Hearing Policy

Credentials / Peer Review Committee Meeting