Humana Military has established minimum credentialing/eligibility criteria for inclusion in the provider network. Failure to meet the minimum credentialing/eligibility criteria established by the credentialing committee is not reportable to any external agency (i.e. the NPDB).
To appeal a decision, Humana Military must receive notification of the appeal within 14 calendar days of the provider’s notification that minimum credentialing/eligibility was not met. All documentation must be included to support the appeal. The first level review panel will review the appeal and documentation. Notification of outcome will be in writing. Failure to comply within the 14 calendar day period constitutes a waiver of the right to appeal.
Note: The TRICARE Policy Manual, 6010.60-M, April 2015, Chapter 11, Section 3.2, State Licensure and Certification Policy states, “A. State Licensure/Certification. Otherwise-covered services shall be cost-shared only if the individual professional provider holds a current, valid license or certification to practice his or her profession in the state where service is rendered. The licensure/certification must be at the full clinical level of practice. Full clinical practice level is defined as an unrestricted license that is not subject to limitations on the scope of practice ordinarily granted all other applicants for similar specialty in the granting jurisdiction.”
Individuals placed on probation or whose license has otherwise been restricted are not considered to be practicing at the full clinical practice level.