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Member Services Phone Number 888.301.1228

Credentialing

Gold Coast Health Plan is committed to ensuring access to a high-quality healthcare delivery system. We contract with high-quality institutions, Providers and allied health professionals to ensure that Members receive quality healthcare and services.

The Credentials Committee is responsible for credentialing and recredentialing all healthcare Providers as verification of a Provider's professional qualifications. All credentialing and recredentialing are performed in accordance with National Committee for Quality Assurance (NCQA) standards and guidelines. Credentialing documents are obtained through the Council for Affordable Quality Healthcare (CAQH). Providers who do not have a CAQH file may be required to complete a Practitioner Credentialing Application. Gemini Diversified Services, a credentialing verification organization, conducts primary source verification, data collection and reporting services.

All Providers must be qualified in accordance with current applicable legal, professional and technical standards and appropriately licensed, certified or registered. All Providers must have good standing in the Medicare and Medicaid/Medi-Cal programs. Providers that have been terminated from either Medicare or Medicaid/Medi-Cal cannot participate in Gold Coast Health Plan. The Credentials Committee makes the decision to accept, retain, deny or terminate a practitioner's participation in Gold Coast Health Plan. The Credentials Committee does not make credentialing or recredentialing decisions based on an applicant's age, gender, race, ethnic/national identity, sexual orientation or types of procedures performed by the applicant.

Gold Coast Health Plan may delegate specific credentialing and recredentialing responsibilities to qualified entities. Before delegation is granted, the entity must submit written policies and procedures related to credentialing activities of potential Plan Network Providers. The written policies and procedures must meet Plan requirements for credentialing and recredentialing. Gold Coast Health Plan designated staff, the chief medical officer and the Credentials Committee have responsibility to perform oversight of any delegated entity's credentialing and recredentialing activities to ensure full compliance with Gold Coast Health Plan policies and to make recommendations for improvement as appropriate. If the delegated entity fails to fulfill its obligations, Gold Coast Health Plan will retain the right to revoke delegation.

Credentials / Peer Review Committee Meeting

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