Join the Banner|Aetna Network
Credentialing Overview
If you are joining the Banner|Aetna network, you will be credentialed according to Aetna standards as outlined below:
Aetna shall maintain a network that will be credentialed and recredentialed consistent with the accrediting bodies of National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS) and URAC, as well as state and federal requirements.
Aetna will consider the following factors in its credentialing process and secure primary source verification, as required:
- Licensure and/or certification verified through state licensing boards in geographical areas where network practitioners will care for our members
- Board certifications (when applicable)
- Loss of/limitation of hospital admitting privileges (when applicable)
- Current professional liability coverage
- Drug Enforcement Agency (DEA) and state controlled-drug substance registration, when applicable, through verification by the U.S. Department of Commerce National Technical Information Service (when applicable)
- Disciplinary history or adverse actions related to licensure and DEA registration, which we query through state licensing boards and the National Practitioner Databank (NPDB)
- Malpractice insurance claim history to examine any possible trends and to look for evidence that might suggest any probable substandard professional performance in the future
- Mental and physical health to determine if the practitioner’s history might suggest any probable substandard professional performance in the future
- Participation in government programs such as Medicare or Medicaid
- Professional education and training through verification by the American Medical Association (AMA) Masterfile, American Osteopathic Association (AOA) and specialty board or specific residency/training program (highest level of education, depending on practitioner type)
- Work history
The Aetna Credentialing and Performance Committee (CPC) has authority for making final determinations for those individual practitioners being considered for exceptions to Aetna’s established requirements for professional competence and conduct.
Individual practitioners will be recredentialed using the Aetna standard credentialing process every three (3) years.
In addition, in between formal credentialing cycles, Aetna will monitor the following as part of the ongoing quality review:
- state board sanctions
- loss of license
- Office of Personnel Management/Office of Inspector General reports
- Medicare Opt Out
- Member complaints
- Internally identified potential quality of care concerns
