Physician and Provider Selection Criteria
RMHP does not use quality measures, member experience measures, or cost-related measures to select practitioners or facilities. In establishing and maintaining our network of providers, RMHMO endeavors to provide care within a reasonable travel time and distance to Members. To achieve this, RMHP contracts with most available acute care hospitals, primary care physicians (PCPs), specialists and sub-specialists who meet RMHMO’s credentialing and quality standards within the service area.
All practitioners and hospitals who are part of RMHP provider networks must meet credentialing requirements. RMHP reviews credentialing information provided by practitioners and hospitals before they become part of our network. Every three years, RMHP’s practitioners and hospitals must supply updated information to us, which we review again. RMHP verifies information that is supplied, such as where a physician received training and if the physician has a current license to practice.
RMHP instructs practitioners and hospitals to notify us with updates in address, phone number, hospital or group affiliations, and accepting new patients in a timely manner. The information us updated in the provider directory within 30 calendar days of receiving new information. Information updates are sent weekly to the online provider directory website.
Practitioners and hospitals may self-report , or update upon RMHP’s request, the demographic information displayed in the directory (name, address, phone number, gender, languages spoken, medical group affiliation, hospital affiliation, accepting current patients). RMHP reviews this information annually. The information is also reviewed during recredentialing every three years.
This data is updated weekly to maintain accuracy. The Directory is current as of Wednesday of each week. However, please contact Customer Service at 1-800-842-0719 if you contact your provider and find that information is out of date.
A specialty is the medical field in which a physician has training such as orthopedics or cardiology. Physicians self-report their specialties, which RMHP then verifies with external sources at the time of credentialing, recredentialing, and whenever a physician notifies us of a change. The information is also reviewed during recredentialing every three years.
Medical Group Affiliations
This refers to the name of the physician’s practice. It may be a group practice with other doctors. The information is reviewed during recredentialing twice per year.
This refers to the language(s) other than English that a physician or his/her clinical staff can speak to those needing medical care. This information is voluntarily reported by the physician at the time of credentialing and recredentialing. A physician may notify us of changes at any time. The information is reviewed during recredentialing every three years.
Physicians are Board certified if, after completing residency training in a specialty, they pass an exam and meet requirements established by their Board. Board certification is voluntary. RMHP verifies this information with the American Board of Medical Specialties or the American Osteopathic Association when the physician becomes a participating provider with us and at least every three years thereafter. Board certification provides a trusted credential that is important to patients and relevant to a physician practice. The information is reviewed during recredentialing every three years. You can see a physician’s current Board status by visiting www.abms.org or www.osteopathic.org.
Acceptance of New Patients
This indicates whether a physician is receiving new patients into his/her practice. Physicians self-report to RMHP whether they are accepting new patients. This information is validated annually.
Hospital Privileges refers to a hospital where a particular physician may treat patients. Hospital affiliation is reported to RMHP by the physician at the time of credentialing and recredentialing. A physician may notify RMHP of changes at any time.
The hospital name, type of hospital (i.e. acute, rehabilitation, children’s, cancer), location, languages spoken, accepting new patients, providers who have privileges at the hospital, and accreditation status are shown. The facility name and location are verified every three years at Recredentialing.
An independent accreditation organization has recognized a hospital as meeting predetermined standards for quality of care and service. Two examples are the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission) and National Integrated Accreditation for Healthcare Organizations (NIAHO). Joint Commission hospital accreditation is verified through the accrediting body's website www.qualitycheck.org at Initial Credentialing of the hospital. The information is also reviewed during recredentialing every three years. Hospital accreditation status may be verified at any time at www.qualitycheck.org.
Typically, an organization that provides quality data brings together and summarizes the data they receive from multiple organizations. They are responsible for the accuracy of the Quality Data.
Quality Check is the Joint Commission’s search engine to locate Joint Commission accredited health care organizations in the United States. This information can be used by members when selecting a hospital. Members can search by city, zip code, or hospital name. To find information about a hospital’s quality data go to www.qualitycheck.org
The Monument Health Network is a tiered network; there are two tiers of providers. Your care is covered in different ways. Each time you seek medical care, you decide how and from whom to receive care.
- If you receive covered services from a Tier 1 PCP type provider (or covering physician if your PCP is not available), you will pay lower copay.
- If you receive covered services from a Tier 2 PCP or network provider other than a PCP type provider, your copay will usually be higher.
- You pay more for covered health care services you receive from a licensed health care provider who does not participate with RMHP.
Please refer to your Evidence of Coverage to determine copay amounts applicable to your plan.
If you need help finding a network provider and/or pharmacy, please call RMHP Customer Service at 888-282-1420 (TTY 711). If you would like a Medicare Provider/Pharmacy Directory mailed to you, you may call the number above or email customer_service@RMHP.org.