Provider Credentialing: Maintaining Provider Enrollments, Updates, and Re-Validations

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Provider Credentialing
Maintaining Provider Enrollments, Updates, and
Re-Validations
A Webinar Presented by Cati Harris, CBCS,
CPCS Director of Provider Credentialing - Solor,
Inc
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Cati Harris, CBCS, CPCS
Director of Provider Credentialing Contracting
Solor, Inc.

• Professional Experience
• Over 20 years experience in Medical Billing,
  Coding, Provider Credentialing/Contracting
• 15 years clinical experience
• Currently provide credentialing services for 2
  major hospital systems, and 15 private practices
  (40 physicians/PA/NP)
• Educational Experience
• Diploma with Honors in Medical Billing Coding
• Certi?ed Billing and Coding Specialist
• Certi?ed Provider Credentialing Specialist

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Learning Objectives

• Welcome to the Webinar! Provider Credentialing
  Maintaining Provider Enrollments, Updates, and
  Re-Validations. This webinar covers the
  credentialing process including provider
  enrollment maintenance, CAQH/PECOS Maintenance,
  and revalidations. t
• When to start credentialing
• What is needed to maintain provider enrollment
  with payers?
• Setup and Maintenance of NPPES, IA Management
  System, CAQH, PECOS
• How to review, validate, and track provider
  documents
• How to Prepare, Review, Submit, and Track Payer
  applications
• Linking of a previously credentialed provider
  with payers to your tax id/contracts
• Re-Validations
• Credentialing Tips

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Credentialing Keys to Success

• Research
• Preparation
• Tracking
• Communication

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Provider Research

• Provider Research includes questions to ensure
  you have the vital information to proceed with
  the Providers credentialing.
• Does the provider have a registered NPI?
• Is the provider newly licensed?
• What is the providers anticipated start date?
• State Approved Medical License
• Does the provider have any disciplinary actions,
  previous criminal charges, or malpractice
  claims?
• Mid-Level - Is the supervising md approved?
• Mid-Level - Is the collaborative agreement
  signed?
• Has the provider been previously credentialed
  with payers?

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Research - Provider

• Provider Welcome Packet
• Welcome Letter
• Include a brief introduction of yourself
• Provide Contact Information and O?ce Hours
• Description of Services
• Provide Description of the services you will be
  providing for the provider
• Maintenance of CAQH, NPPES, I/A System
• Include your fee for credentialing services
• Include payment information and payment terms
• Clearly De?ne the Expectations of the
  Provider/Provider Support Staff for return of
  documents and communication.
• Provide timelines of document return expectations

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Provider Enrollment Information Document
Provider Welcome Package Documents
Provider Document Checklist Provider CV
Requirements Welcome Letter
Tip Please email cballard_at_mysolor.com for a
copy of the documents referenced in this webinar
Description of Services
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Payer Documents
Payer/State Applications Payer/State Applications

Payer Contact Information Payer Contact Information

Tracking Spreadsheet Tracking Spreadsheet
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Provider Document Preparation

• Review All Documents for Accuracy, Dates,
  Infractions
• Verify Licensure and Board Certi?cations are
  current with no infractions - Explain previous
  disciplinary actions
• Verify Malpractice Insurance is for current group
  and review for previous claims
• Previous Malpractice Claims - Provider must
  provide detailed information/explanation
• Verify DEA License is Current without restriction
• Create a Provider File
• This ?le will contain all original documents.
• It is suggested to save a copy of the originals
  in a secure location on your computer.
• Organization of the Provider File (Two Sided
  Folder)
• Access Provider Logins
• CAQH, PECOS, IA, NPPES
• Attest CAQH every 60 days (120 days is
  requirement)

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NPPES, CAQH, Identity Access Management, PECOS

• When credentialing a provider, you will need to
  access various management systems to ensure the
  information is accurate, current, and attested.
  The managements systems to access
• NPPES
• Identity Access Management System
• CAQH
• PECOS

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NPPES

• NPPES - https//nppes.cms.hhs.gov//
• Obtain Login/PW or Setup access (The login for
  the IA System is the same for NPPES)
• Verify Provider Information
• Correspondence Address and Practice Address
• Provider Contact Information
• Phone number, Email
• Taxonomy
• Delegated Access
• Provider IDs
• NPPES Must be current and approved before
  proceeding with any provider credentialing.
• Print out any update con?rmations completed

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NPPES
Now we will see an example of the NPPES system
and each section. This information will show
from the start to ?nish in NPPES
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CAQH

• CAQH - https//proview.caqh.org/Login/Index?Return
  Url2f
• Obtain Login/PW or Setup access
• Review/Complete each section
• Add your information in the credentialing contact
• Add your email on the provider info page as a
  secondary contact
• Ensure the Authorization Section is Checked to
  Allow all Payer Access
• Upload the following documents
• Attestation
• Certi?cate of Insurance
• State License
• DEA
• Provider CV
• Board Certi?cation
• Med School Degree including any Residency or
  Fellowship Cert

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PECOS

• PECOS - https//pecos.cms.hhs.gov/pecos/login.doh
  eadingLv1
• The login for PECOS is the same username and
  password used for IA Management System
• Select My Associates
• Scroll to bottom and check for current
  enrollments
• If provider is currently enrolled, check to see
  if the provider is enrolled with the correct
  state and MAC.
• If provider is not enrolled, you will select to
  start the process.
• Complete all tabs, run an error check, locate
  name of group authorized signatory for the
  reassignment of bene?ts
• Once error check shows no errors, you can
  complete submission
• Be sure to print out copy of application and
  submission
• You will receive email con?rmation
• Re-Validations
• Select revalidation noti?cation center instead of
  My Associates

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Payer Document Preparation

• Review Payer Application Requirements
• Complete Payer Application
• Organize/Review Application Package with
  Required Documents
• Prep Application Package Cover Letter
• Check current payer processing times
• Submit Complete Application Package to Payer

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Provider Revalidation

• All Payers require re-credentialing/re-validation
  once the provider is credentialed.
• Important Information Regarding Provider
  Re-Validations/Re-Credentialing
• When the provider is initially credentialed,
  inquire with payer when the re-credentialing will
  be due.
• Most payers are either every 3 years or Every 5
  years
• Maintain a database or spreadsheet for each
  provider with the payers re-validation dates
  listed.
• At least 60 days prior to re-validation due date,
  inquire with the payer the requirements for the
  providers re-validation
• Ensure CAQH is up to date and attested prior to
  inquiring or beginning re-validations.
• PECOS aka Medicare Re-validations are every 5
  years
• Select revalidation noti?cation center instead of
  My Associates within PECOS to obtain due date
  of re-validation and to complete the process.

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Tracking is the single action that can ensure
timely, e?cient submission and processing of the
providers payer application package.
Tracking

• Lack of tracking can lead to
• Payer misplacing application package
• Delayed application submission and processing
• Missed request for more information, missing
  documentation
• Application being Red Flagged by Payer
• Financial loss and increased credentialing costs

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• Tracking is Divided Into Two Parts
• Document Tracking
• Application Tracking

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Communication

• Communication is the key to successful and
  timely processing of your providers
  credentialing application.
• Keys to successful communication
• Consistent updates provided to the provider and
  appropriate administrative staff via live google
  doc links and/or Emails
• Consistent tracking and follow up on the status
  of the submitted payer applications.
• Tracking the payer provided estimated processing
  times.
• Updating/Maintaining Tracking Tools

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Steps to Minimize Financial Impact

• Begin the credentialing process a minimum of 60
  days before provider anticipated start date.
  Preferably 90 days.
• Maintain CAQH and attest every 120 days
• Ensure IA, NPPES login stay up to date with
  accurate information.
• Consistently follow up with payers to ensure
  timely processing.
• Organize and maintain all provider data,
  documents, and applications. Update frequently.
• Timely Provider and administrative staff
  credentialing status updates.
• Maintain Live Update Document (Google Sheet, One
  Drive, MS Teams, Etc)
• Maintain tracking spreadsheet for provider payer
  applications submissions and updates.
• For Mid-Levels only, Bill as Incident Too

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Once the Provider Credentialing is Approved..

• What is next?
• Request copy of approval/welcome letter from
  payer
• Request payer speci?c provider
• Inquire when the revalidation will be due
• Request copy of contract and fee schedule
• Review both the contract and fee schedule prior
  to signing
• Once signed, request copy of signed contract
• Create Master Information Sheet with payer
  speci?c information
• Credentialing effective date
• Payer Speci?c Provider
• Contract Effective Date
• Fee Schedule Effective Date

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Questions?
Cati Harris, CBCS, Director of Provider
Credentialing Solor, Inc Phone
704-675-7279 Email cballard_at_mysolor.com Thank
you for your time and attendance!
Register Now