Resources
Documents and Forms
We have assembled important resources on this page to equip you with the knowledge you need to serve your patients. Below are documents and forms for providers in our network:
- Case Management Referral Form
- Credentialing Application
- Clinical Practice Guidelines
- EFT Instructions
- Financial Responsibility
- HIPAA Privacy Authorization Form
- Coverage Determination for Non-Formulary Prescription Drugs
- OTC Catalog
- OTC Order Form
- Request for Service Authorization
- Shared Decision-Making Aids
- Member Rights & Responsibilities
Credentialing
The Solis Health Plans Credentialing Program strives to ensure that the Solis Health Plans’ network consists of quality Practitioners/Ancillary/Facilities who meet clearly defined criteria and standards. It is the objective of Solis Health Plans to provide superior health care to the community. The decision to accept or deny a credentialing applicant is based upon primary source verification, recommendation of peer practitioners/providers and additional information, as required. The information gathered is confidential and disclosure is limited to parties who are legally permitted to have access to the information under state and federal law. The Credentialing Program has been developed in accordance with state and federal requirements and accreditation guidelines. In accordance with those standards, Molina Healthcare members will not be referred and/or assigned to you until the credentialing process has been completed.
Criteria for Participation
During the credentialing process, Solis Health Plans will work with you to verify your qualifications, practice history, certifications, and registration to practice in the health care field. Solis Health Plans has established criteria and resources used to verify these criteria for the evaluation and selection of practitioners for participation. Solis’ policy defines the criteria that is applied to applicants for initial, recredentialing, and ongoing participation in the Solis network.
Solis Health Plans reserves the right of discretion in applying any criteria and excludes practitioners who do not meet the criteria. Solis may, after considering the recommendations of the Credentialing Committee, waive any of the requirements for network participation established pursuant to these policies for good cause if it is determined that such waiver is necessary to meet the needs of Solis Health Plans and the community it serves.
The refusal of Solis Health Plans to waive any requirement shall not entitle any practitioner to a hearing, appeal, or any other rights of review.
Practitioners must meet the following criteria to be eligible to participate in the Solis network. If the practitioner fails to provide proof of meeting these criteria, the credentialing application will be deemed incomplete, and it will result in an administrative denial or termination from the Solis network.
- Practitioner must practice, or plan to practice within 60 calendar days, within the area served by Solis.
- All providers, including ancillary providers, must be participating with Medicare. If provider has proof of application submission to Medicare, credentialing may choose to process the credentials for the provider, depending on network necessity.
- Practitioner must have a current, valid license to practice in Florida.
- Practitioner must have current professional malpractice liability coverage or Florida financial responsibility form completed.
- If applicable to the specialty, practitioner must have a current and unrestricted Federal Drug Enforcement Agency (DEA) certificate and Controlled Substance Certification or Registration or a prescribing agreement.
- Successful completion of a training program accredited by the Accreditation Council for Graduate Medical Education (ACGME), the American Osteopathic Association (AOA) in the United States or by the College of Family Physicians in Canada (CFPC) or the Royal College of Physicians and Surgeons of Canada. Oral Surgeons must have completed a training program in Oral and Maxillofacial Surgery accredited by the Commission on Dental Accreditation (CODA).
- Current Board Certification by a board recognized by the American Board of Medical Specialties, the American Osteopathic Association, the American Dental Association in the credentialed area of practice, the American Board of Podiatric Surgery, the American Board of Podiatric Orthopedic and Primary Medicine (ABPOPM), or the American Board of Oral and Maxillofacial Surgery. Practitioners who are not Board Certified as described above and have not completed an accredited Residency program are only eligible to be considered for participation as a General Practitioner in the Solis network.
- At the time of initial application, the practitioner must not have any pending or open investigations from any state or governmental professional disciplinary body. This would include Statement of Charges, Notice of Proposed Disciplinary Action, or the equivalent.
- Practitioner must not be currently excluded, expelled, or suspended from any state or federally funded program including, but not limited to, the Medicare or Medicaid programs.
- Practitioner must not have been convicted of a felony or pled guilty to a felony for a healthcare related crime including, but not limited to, healthcare fraud, patient abuse and the unlawful manufacture distribution or dispensing of a controlled substance.
Credentialing Requirements for Licensed Independent Practitioners
- Practitioner degree (MD, DO, DPM, NP, PA), post-graduate education or training.
- Details of medical or professional education and training.
- Completion of residency program in the designated specialty.
- Current license or certification in Florida in which the care provider will be practicing (no temporary licenses).
- National Provider Identification (NPI) number.
- Active Drug Enforcement Agency (DEA) number and/or Controlled Dangerous Substance (CDS) Certificate or acceptable substitute (if required).
- Medicare participation required.
- Five-year work history.
- If there are any gaps longer than six months, please explain.
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Statement of work limitations, license history and sanctions.
The statement must include:- Any limitations in ability to perform the functions of the position, with or without accommodation;
- History of loss of license and/or felony convictions;
- History of loss or limitation of privileges or disciplinary activity.
- W-9 form.
- Hospital staff privileges.
- Active errors and omissions (malpractice) insurance or a state-approved alternative.
- Malpractice history.
- Other Credentialing requirements such as AMA profile or criminal history review as required by Credentialing Authorities.
- Notification if this provider has ever been a delegated provider prior to this credentialing application.
- Passing score on state site visit (if required).
Each facility must meet the following criteria to be considered for credentialing:
- Current required license(s).
- Commercial/Professional liability insurance.
- Errors and omissions (malpractice) insurance.
- Proof of Medicare/Medicaid program participation eligibility.
- Appropriate accreditation by a recognized agency, or satisfactory alternative.
- Centers for Medicare & Medicaid Services (CMS) certification
- Nondiscrimination during the credentialing process.
- Strict confidentiality of all information submitted during the credentialing process.
- Be notified of information obtained during the credentialing process that varies substantially from what is submitted by you.
- Review information submitted to support your credentialing application, with the exception of references, recommendations or other peer-review protected information.
- Be informed of the status of your application upon request, you can contact the Credentialing Department at credentialing@solishealthplans.com.
- Receive notification of Solis Health Plans credentialing decision within 60 days of the committee decision.
- Receive confirmation that listings in practitioner directories and other materials for members are consistent with credentialing data, including education, training, board certification and specialty.
- Receive notification of your rights as a provider to appeal an adverse decision made by the committee.
- Be informed of the above rights.
Correctness and Completeness
Correctness and completeness of the application Practitioners/Facilities must attest that their application is complete and correct when they apply for credentialing and recredentialing. Solis uses CAQH ProView Application as the required application for providers, and the Solis application for facilities. All applications must be attested within 120 days for the application to be accepted.
Non-Discriminatory Credentialing and Recredentialing
Solis does not make credentialing and recredentialing decisions based on an applicant’s race, ethnic/national identity, gender, age, sexual orientation or the types of procedures (e.g. abortions) or patients (e.g. Medicaid or Medicare) in which the practitioner specializes.
Notification of Discrepancies in Credentialing Information
Solis will notify the practitioner immediately in writing in the event that credentialing information obtained from other sources varies substantially from that provided by the practitioner. Examples include but are not limited to actions on a license, malpractice claims history or board certification decisions. Solis is not required to reveal the source of information if the information is not obtained to meet organization credentialing verification requirements or if disclosure is prohibited by law.
Practitioners Right to Correct Erroneous Information
Practitioners have the right to correct erroneous information in their credentials file. Practitioners are notified of their right in a letter sent to them at the time the initial or recredentialing application is received.
Solis will notify the practitioner immediately in writing in the event that credentialing information obtained from other sources varies substantially from that provided by the practitioner. Examples include but are not limited to actions on a license or malpractice claims history. Solis is not required to reveal the source of information if the information is not obtained to meet organization credentialing verification requirements or if disclosure is prohibited by law.
The notification sent to the practitioner will detail the information in question and will include instructions to the practitioner indicating:
- Their requirement to submit a written response within 10 calendar days of receiving notification from Solis.
- In their response, the practitioner must explain the discrepancy, correct any erroneous information, and may provide any proof that is available.
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The practitioner’s response must be sent to:
Solis Health Plans, Inc.
Attention Credentialing Department
9250 NW 36 Street, Ste 400
Doral, FL 33178
Upon receipt of notification from the practitioner Solis Health Plans will document receipt of the information in the practitioner’s credentials file. Solis will then re-verify the primary source information in dispute. If the primary source information has changed, correction will be made immediately to the practitioner’s credentials file. The practitioner will be notified in writing that the correction has been made to their credentials file. If the primary source information remains inconsistent with practitioners’ notification, the Credentialing Department will notify the practitioner. The practitioner may then provide proof of correction by the primary source body to Solis’s Credentialing Department. The Credentialing Department will re-verify primary source information if such documentation is provided.
If the practitioner does not respond within 10 calendar days, their application processing will be discontinued, and network participation will be denied.
Practitioners Right to be Informed of Application Status
Practitioners have a right, upon request, to be informed of the status of their application. Practitioners applying for initial participation are sent a Practitioner Rights letter when their application is received by Solis Health Plans and are notified of their right to be informed of the status of their application in this letter. The practitioner can request to be informed of the status of their application by telephone, email, or mail. Solis may share with the practitioner where the application is in the credentialing process to include any missing information or information not yet verified. Solis Credentialing does not share with or allow a practitioner to review references or recommendations, or other information that is peer-review protected.