Provisional Employment Agreement

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Provisional Employment Agreement Powered By Docstoc

1. The UA Department makes an offer, which is accepted by the physician recruit. The department
   initiates the UA faculty paperwork. The physician should initiate an Arizona license application as
   soon as possible if he/she is not already licensed in Arizona. This can take 12 weeks.
2. The UA Department completes the New Physician/Provider Data Form (NPPDF) and sends it,
   along with physician’s CV, to the UPH Chief Medical Officer’s Office (CMOO), UMC Rm. 2302A, to
   Peggy Goforth or San Harrison. The UA Department is also responsible for directly contacting the
   UMC Office of the Chief of Staff and any other outside hospitals (as applicable) to request
   privileges, and UPH Human Resources (HR) for employment of part-time physicians.
3. UPH CMOO staff review the NPPDF and contact the department for additional information as
   needed. The NPPDF is then faxed to Shannon Modrak (Credentialing), Sherrie Motisko (Contracts),
   Tanya Casares (Business Operations), Gerry Hittle (Human Resources), Darla Yutsyk (Benefits),
   Sharon Crowder (Employee Health), and the UPHK Medical Staff Office (if UPHK hospital/clinic
   privileges are required). An NPPDF is also faxed to UMC’s Office of the Chief of Staff (if
4. The UPH Credentialing Department enters data into the CACTUS database and generates a pre-
   populated credentialing application and contracted health plan applications (BC/BS, CCRS),
   Medicare and AHCCCS provider registration forms, and a UPHK privileging packet (as applicable.
   Please note that a joint UPH/UMC credentialing application is used for those providers requiring
   credentialing/privileging with both organizations. UPH has its own credentialing application for
   providers who will not practice at UMC.
5. All credentialing forms are provided to the designated UA department contact person to have the
   physician complete the forms. It is critical that these forms be returned as soon as possible so that
   the credentials verification process can begin. If the department office is located at UMC/AHSC, the
   forms should be returned to Peggy Goforth or San Harrison in Room 2302A, rather then sending
   directly to the Credentialing Department located on the Kino Campus. It is strongly recommended
   that these be hand-delivered to avoid delays in campus mailing process. Peggy or San will make
   sure that the forms are hand-delivered to the designated credentialing staff to assure that
   paperwork is not lost.
6. When the completed credentialing forms are received by the UPH Credentialing Department, they
   are reviewed for completeness. Completed payer forms are forwarded to Tanya Casares in
   Business Operations for submission to Medicare and AHCCCS. Non-delegated Health Plan
   applications (BC/BS, CCRS) are submitted to the plans according to their policies and procedures.
   UPHK privileging forms are forwarded to the UPHK Medical Staff Office. The joint UPH/UMC
   credentialing application packets are submitted to the UMC Office of the Chief of Staff for primary
   source verification. UPH-only physician applications are submitted for primary source verification to
   Credentialing Solutions, UPH’s current Credentials Verification Organization (CVO) for non-UMC
7. The CVO (or UMC) verifies the physician’s credentialing information (education, training, license,
   employment, malpractice history, references, etc.) with primary sources and returns a verified file to
   UPH Credentialing. This process may take from 60-90 days.
8. Prior to credentialing and employment, the UA department is responsible for submitting an initial
   draft of the appropriate employment agreement (Member Practice Agreement or part-time Contract
   for Professional Services) to the UPH CMOO where it will be reviewed for completeness and typed
   in preparation for signature. The CMOO is required to submit each Contract for Professional
   Services to the UPH Compensation Department for review of compensation prior to signature. Due
   to this required review process, departments are encouraged to submit the initial draft sufficiently in
   advance for this to occur prior to credentialing approval and physician’s UPH employment. Please

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   note that the Compensation Department will generally require that compensation be listed by hourly
9. If a physician needs UPHK privileges, the UPH credentialing and UPHK privileging processes need
   to be synchronized.

10. If the UA Department requests temporary/provisional credentials approval (not automatic) for the
    physician, all the items required per the UPH credentialing checklist must be submitted in a timely
    fashion to the CMOO so that the file may be presented for approval by the CMO, who also chairs
    the UPH Credentials Committee. Please note that UMC privileges are required for UPH
    credentialing if a physician’s responsibilities include hospital practice activities and if UMC is listed
    in the employment agreement as a practice site. UMC temporary privileging is not standard, but
    must be pursued by the department with the UMC Office of the Chief of Staff, which will expedite
    only “clean” files in this manner. UPH temporary/provisional credentials status does not apply to
    contracted health plans. A physician with UPH temporary/provisional credentials status is eligible to
    bill only self-pay, Medicare, and UPH’s AHCCCS sponsored programs of University Family Care
    (UFC) and Health Care Group (HCG) patients.
11. If other required items such as the physician’s signed (by physician and department head) UPH
    employment contract (Member Practice Agreement or part-time Contract for Professional Services)
    and other credentialing checklist documents have been received, and UPHK and UMC privileges
    have been approved (as applicable), the physician’s file is taken to the next UPH Credentialing
    Committee meeting (1st Wednesday of month) for final review and approval. “Clean” files can be
    expedited by UPH with the approval of the CMO and do not have to wait for Credentialing
    Committee approval.
12. In addition to standard credentialing requirements, UPH physicians are also required to complete I-
    9 documentation for UPH by presenting appropriate documents to UPH staff in the CMOO prior to
    their start date. They are also required to complete UPH Ethics and Compliance on-line training.
    Information about this training process is provided to the physician by the CMOO staff.
13. Physicians and their departments are notified of approvals in writing.
14. Staff in the CMOO submits the physician’s UPH employment agreement to the UPH
    President/CEO, Norm Botsford, for final signature. The physician will be sent an original signed
    agreement for his/her personal files.
15. Delegated health plans are notified of UPH credentialing approvals and notify the UPH Contracts
    Department and/or Credentialing Department of the physician’s effective date with the health plan.
    Time frames vary according to each health plan’s policies and procedures for loading new providers
    into their systems, but average 30-60 days.
16. Non-delegated health plans (currently BC/BS, CCRS) complete their separate credentials
    verification and approval procedures and notify UPH Contracts or Credentialing of final approval.
    Physicians are not eligible for reimbursement until the contracted health plans approve and load
    them into their system according to their policies and procedures.
17. The UPH Contracts Department notifies clinical departments of health plan approvals when the
    information is received from the individual health plans.
18. The UPH CMOO notifies a mailing list of all UPH credentialing approvals.
19. All credentialing information is entered and tracked in the CACTUS credentialing database.

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1. Physicians terminating UPH employment must do so according to the terms of their UPH
   employment agreement and UPH policy. (See UPH Policy A238)
2. Upon acceptance of terms of termination with the individual physician, the UA department is
   responsible for submitting written notification to the Chief Medical Officer’s Office in a timely fashion
   via either a Physician Change of Status form or letter stating specific dates and other relevant
   information. Back-up documentation such as resignation and acceptance letters should be
   submitted along with the termination notification. (See UPH Policy A233.)
3. The UPH Chief Medical Officer’s Office and Credentialing Department notify appropriate individuals,
   departments, agencies and health plans according to established policies and procedures.

Other Changes in Employment Status (information changes, FTE, Leave of Absence, etc.)

1. Other changes in a physician’s employment status and related information and documentation
   should be submitted in writing to the UPH Chief Medical Officer’s Office in a timely fashion via the
   Physician Change of Status form. (See UPH Policy A233 & A234.) Any related back-up
   documentation should be submitted along with this form.
2. Changes in practice related information such as specialty or practice sites should be communicated
   directly to the UPH Contracts Department by submitting a completed UPH Provider Database
   Change Authorization form.

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